Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 92928, 92978, 93458, 93571, 99152, and 
99153 rendered on April 26, 2023. 
 
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 92928: 
 
Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch 
 
CPT 92978: 
 
Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or optical coherence 
tomography (OCT) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, 
interpretation and report; initial vessel (List separately in addition to code for primary procedure) 
 
CPT 93458: 
 
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for 
coronary angiography, imaging supervision and interpretation; with left heart catheterization including 
intraprocedural injection(s) for left ventriculography, when performed 
 
CPT 93571: 
 
Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or 
graft) during coronary angiography including pharmacologically induced stress; initial vessel (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 
 
CPT 99153: 
 
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; each additional 15 minutes intraservice time (List separately in addition to code for 
primary service) 
 
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 the codes in question are not 
supported by the documentation submitted. The documentation consists of flow sheets and logs; there is no 
description of the procedure(s) performed by the physician. It cannot be confirmed that these procedures were 
performed as billed. 
 
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 92928, 92978, 93458, 93571, 99152, and 99153 rendered on April 26, 2023.