Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 0715T. We decided that the Plan does not have to pay for 76937 and 
99152.  
 
You asked the Plan to pay for procedure codes 0715T, 76937, and 99152 rendered on April 5, 2023.. You say 
that this should be paid for. The Plan says that the denied codes remain not supported. 
 We decided that the Plan has to pay for 0715T.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of 0715T is "Percutaneous 
transluminal coronary lithotripsy (List separately in addition to code for primary procedure)." 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request for 0715T. Our reviewer says that the procedure notes 
from this date did include evidence of transluminal lithotripsy (Shockwave IVL balloon) being performed. 
Therefore, this code can be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
0715T.  
 
We also decided that the Plan does not have to pay for 76937 and 99152. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of the rest of the codes is: 
 
CPT 76937: 
 
Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary procedure) 
 
CPT 99152: 
 
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 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request for these codes. Our reviewer says that the records did 
not provide the details of the ultrasound findings, with recordings of the ultrasound procedure, as required for 
this code. Additionally, there was no documentation of an independent trained observer for the moderate 
sedation administered, as required for this code. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 76937 and 99152 have not been met. Therefore, we decided that the Plan does 
not have to pay for 76937 and 99152. 
 
 
 
 
 
 
 
 
 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.