Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 76937. We decided that the Plan does not have to pay for 37232 and 99152.  
 
You asked the Plan to pay for procedure codes 37232, 769937, and 99152 rendered on November 29, 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 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 CPT 76937 
codes ultrasound guidance for access. There is satisfactory documentation that this was performed to justify 
billing. Recognizing that it is the providers responsibility to ensure that the images are saved, a requirement 
that the operative report include a statement that images from the ultrasound were saved seems unreasonably 
excessive.   
 
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 [Item/Service Unfavorable]. 
 
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 upheld codes is: 
 
CPT 37232: 
 
Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; 
with transluminal angioplasty (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 
 
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 37232 and CPT 99152. Our reviewer says that 
CPT 37232 codes for an additional tibial artery angioplasty after initial. The tibioperoneal (TP) trunk is 
bundled into the peroneal artery angioplasty (billed and covered) in this case and is not separately billable. 
 
In terms of CPT 99152, this codes for supervision of moderate sedation. The details of who was doing the 
monitoring is insufficiently documented to overturn the health plan determination with respect to this code. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of [Item/Service Unfavorable] have not been met. Therefore, we decided that the 
Plan does not have to pay for [Item/Service Unfavorable]. 
 
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.