Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 99152 and 99153. We decided that the Plan does not have to pay for 
36247 and 36140.  
 
You asked the Plan to pay for procedure codes 36247-XU, 99152, 99153 and 36140-XU billed for date of 
service September 7, 2022. You say that these services were necessary and are supported in the medical record.  
The Plan says that codes 36247 and 36140 are not supported for separate payment, and codes 99152 and 99153 
are not supported in the medical record because an amended operative report was submitted without clear 
documentation/notes about any amendments, corrections, or delays. 
 
We decided that the Plan has to pay for 99152 and 99153.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 99152 is moderate sedation services provided by the same physician or other qualified health care 
professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence 
of an independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. The definition of code 
99153 is moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; each additional 15 minutes intraservice time (List separately in addition to code for 
primary service). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request 99152 and 99153. Our reviewer found that for code 99152 the 
documentation submitted was reviewed and does meet criteria. The Health Plan denied claim for 
documentation does not support an amended report, however, no documentation was found to support an 
amended report. The operative report clearly documents the criteria for moderate sedation to include a trained 
observer was present and time services were rendered. Therefore, this procedure would be covered. For code 
99153, the documentation submitted was reviewed and does meet criteria. The Health Plan denied the claim for 
documentation not supporting and amended report; however, there is no documentation found to support an 
amended report. The operative report clearly documents the criteria for moderate sedation to include a trained 
observer was present and time services were rendered. Therefore, this procedure would be covered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99152 and 99153 have been met. Therefore, we decided that the Plan has to pay 
for 99152 and 99153.  
 
We also decided that the Plan does not have to pay for 36247 and 36140. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that codes 36247 and 36140 is a column II code to column I code 37228; 
however, codes 36247-XU and 36140-XU were billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for 36247-XU and 36140-XU. Our reviewer says that for code 
36247, the documentation submitted was reviewed and does not meet criteria. The service was reported with 
modifier XU Unusual non-overlapping; however, the operative report does not include documentation to support procedure was unusual non-overlapping from CPT 37228, and therefore, cannot be verified. For code 
36140, the documentation submitted was reviewed and does not meet criteria. The service was reported with 
modifier XU Unusual non-overlapping; however, the operative report does not include documentation to 
support procedure was unusual non-overlapping from CPT 37228, and therefore, cannot be verified. An 
intervention was performed, and therefore, catheter placement would be included. Of note, two separate 
procedure reports were submitted with different dates of service. For this review, procedure reported date 
September 7, 2022, was referenced. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 36247-XU and 36140-XU have not been met. Therefore, we decided that the 
Plan does not have to pay for 36247 and 36140. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.