Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95921, 95922, 95923, 93922, and 93923 
billed for September 27, 2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 95921, 95923, 95922, 93922, and 93923 are not supported. 
 
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 95921 is testing of autonomic nervous system function; 
cardiovagal innervation (parasympathetic function), including 2 or more of the following: heart rate response to 
deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio. The definition of code 95922 is 
testing of autonomic nervous system function; vasomotor adrenergic innervation (sympathetic adrenergic 
function), including beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver and at 
least 5 minutes of passive tilt. The definition of code 95923 is testing of autonomic nervous system function; 
vasomotor adrenergic innervation (sympathetic adrenergic function), including beat-to-beat blood pressure and 
R-R interval changes during Valsalva maneuver and at least 5 minutes of passive tilt. The definition of code 
93922 is limited bilateral noninvasive physiologic studies of lower extremity arteries. The definition of code 
93923 is complete bilateral noninvasive physiologic studies of 3 or more levels of lower extremity arteries. 
 
We find that CPT codes 95921, 95922, 95923, 93922, and 93923 are not supported in the medical record. 
Specifically, there is no documentation of two or more of heart rate response to deep breathing with recorded 
R-R interval, Valsalva ration, and 30:15 ratio to support code 95921. There is no documentation of at least one 
of a quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and 
changes in sympathetic skin potential to support code 95923. There is no documentation of complete bilateral 
noninvasive physiologic studies of upper or lower extremity arteries at three or more levels to support code 
93923. 
 
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, we have confirmed that code 93922 
is a column II code to column I code 93923. Given that code 93923 is not supported, code 93922 cannot be 
supported. Based on the claim submitted, Medicare billing criteria have not been met. 
 
We have confirmed that code 95922 is a column II code to column I code 95921. Given that code 95921 is not 
supported, code 95922 cannot be supported. Based on the claim submitted, Medicare billing criteria have not 
been met. 
 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 95921, 95922, 95923, 93922, and 
93923 billed for September 27, 2022.