Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 93931, 95921, and 95923. We decided that the Plan does not have to 
pay for 93924.  
 You asked the Plan to pay for procedure codes 93924, 93931, 95921, and 95923 rendered on September 21, 
2022. 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 93931, 95921, and 95923.  
 
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 the overturned codes are: 
 
CPT 93931: 
 
Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study 
 
CPT 95921: 
 
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 
 
CPT 95923: 
 
Testing of autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative 
sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in 
sympathetic skin potential 
 
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 these codes.  
 
Our reviewer says that in terms of CPT 93931, this code is supported the report. The records show that a 
unilateral upper extremity duplex scan was performed. The ankle-brachial index (ABI) was calculated. 
 
In terms of CPT 95921, a summation report for cardiovagal innervation testing was present in the records. 
 
In terms of CPT 95923, a summation report for sudomotor testing was present in the records. 
 
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 
93931, 95921, and 95923.  
 
We also decided that the Plan does not have to pay for 93924. 
 
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 
CPT 93924 is "Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill 
stress testing, (ie, bidirectional Doppler waveform or volume plethysmography recording and analysis at rest 
with ankle/brachial indices immediately after and at timed intervals following performance of a standardized 
protocol on a motorized treadmill plus recording of time of onset of claudication or other symptoms, maximal 
walking time, and time to recovery) complete bilateral study." 
 
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 93924. Our reviewer says that the definition 
of this code specifically requires a treadmill be used for exercise. No such documentation is present in the 
records.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 93924 have not been met. Therefore, we decided that the Plan does not have to 
pay for 93924. 
 
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.