Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for 76937. We decided that the Plan does not have to pay for 99152.  
 
You asked the Plan to pay for procedure codes 76937 and 99152 rendered on April 26, 2023.. You say that this 
should be paid for. The Plan says that the records do not support the services billed. 
 
 We decided that the Plan has to pay for 76937.  
 
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 CPT 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 (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 CPT 76937. Our reviewer says that this codes for 
ultrasound guidance for vascular access. There is satisfactory documentation that ultrasound guidance was used 
to access the patent femoral artery.  While there is a stipulation that the images must be archived, it is not 
reasonable to require documentation of this in the operative note. 
 
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 
76937.  
 
We also decided that the Plan does not have to pay for 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 CPT 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." 
 
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 CPT 99152. Our reviewer says that this codes for 
moderate sedation services. There is inadequate documentation of physician supervision or provision of these 
services. There is no record of an independent observer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99152 have not been met. Therefore, we decided that the Plan does not have to 
pay for 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.