Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93923, 93925, 93970, and 99204 rendered 
on December 19, 2022. 
 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 93925: 
 
Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study 
 
CPT 93970: 
 
Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral 
study 
 
CPT 99204: 
 
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically 
appropriate history and/or examination and moderate level of medical decision making. When using time for 
code selection, 45-59 minutes of total time is spent on the date of the encounter 
 
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, the 
procedure report does not support complete bilateral studies, 3 levels or more. The documentation supports a 
limited study. A more appropriate code would need to be reported. 
 
In terms of CPT 93925, the report does not support a complete duplex scan to include arterial inflow and 
venous outflow, and color and spectral doppler. There is a more appropriate code to report for the service 
documented. 
 
In terms of CPT 93970, the procedure report does not include documentation of duplex scan of extremity veins 
including responses to compression and other maneuvers; complete bilateral study. The procedure was not 
found in the medical record.  
 
In terms of CPT 99204, the documentation supports a straightforward level of medical decision making. The 
records describe the enrollee presenting with large varicose veins. The history and examination performed are 
related to the varicose veins, and a duplex scan was ordered. There is a more appropriate code to report for the 
services documented.  
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 codes 93923, 93925, 93970, and 99204 rendered on December 19, 2022.