Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound guidance for vascular access and moderate 
sedation, provided on October 28, 2022, billed with codes 76937, 99152 and 99153. 
 
You asked the Plan to pay for the ultrasound and sedation. You say that medical records submitted support 
codes 76937, 99152, and 99153 and should be paid. The Plan denied your request. The Plan says that the 
documentation submitted does not support CPT codes 76937, 99152, and 99153; the medical records did not 
indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of 
consciousness and physiological status. The Plan also says that the ultrasound guidance is not separately 
reportable with cardiac catheterization, percutaneous coronary artery interventional procedures. 
 
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 76937 is 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. 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; and 
CPT code 99153 is used to report additional intraservice time intervals for this same sedation.. 
 
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 ultrasound and sedation. Our reviewer found that the 
medical records did not provide sufficient documentation to support codes 76937, 99152, and 99153. Our 
reviewer says that although there is evidence that ultrasound guidance was used in this case, it is not separately 
reportable with cardiac catheterization, percutaneous coronary artery interventional procedures. In addition, the 
particular guidance used in this case is not most accurately described by the code reported. The sedation 
services are also not supported, as the documentation submitted did not indicate the presence of an independent 
trained observer to assist in the monitoring of the enrollees level of consciousness and physiological status; 
therefore, the billed services cannot be verified. 
 
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 ultrasound and sedation have not been met. Therefore, we decided that the 
Plan does not have to pay for the ultrasound guidance for vascular access and moderate sedation, provided on 
October 28, 2022, billed with codes 76937, 99152 and 99153.