Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure 93923 and 99214 rendered on July 18, 2023. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 93923: 
 
Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, 
for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries 
plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at 3 
or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus 
segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and 
anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more 
levels), or single level study with provocative functional maneuvers (eg, measurements with postural 
provocative tests, or measurements with reactive hyperemia) 
 
CPT 99214: 
 
Office or other outpatient visit for the evaluation and management of an established patient, which requires at 
least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are 
spent face-to-face with the patient and/or family 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 93923, there is 
no recording or analysis of Doppler waveforms.  Therefore, adding this charge in addition to the charge for 
lower extremity arterial duplex (already paid) cannot be justified. In terms of CPT 99214, this is relatively high 
level code, representing evaluation and management code for an outpatient visit with an established patient. In 
this case there is no documentation of time and no documentation of medical decision making that would rise 
to a level four visit. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure 93923 and 99214 rendered on July 18, 2023.