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Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
Medicare guidance says Professional Component (PC)/Technical Component (TC) Indicator 3 Technical 
component only codes: This indicator identifies stand-alone codes that describe the technical component (i.e., 
staff and equipment costs) of selected diagnostic tests for which there is an associated code that describes the 
professional component of the diagnostic tests only. An example of a technical component code is 93005, 
Electrocardiogram, tracing only, without interpretation and report. It also identifies codes that are covered only 
as diagnostic tests and therefore do not have a related professional code. Modifiers 26 and TC cannot be used 
with these codes. The total RVUs for technical component only codes include values for practice expense and 
malpractice expense only. You can find this guidance in the Medicare Claims Processing Manual Chapter 23 - 
Fee Schedule Administration and Coding Requirements, Addendum - MPFSDB Record Layouts File Layout. 
 
Medicare guidance says Procedure Code 99153 PC/TC -3. You can find this guidance in the 2022 National 
Physician Fee Schedule Relative Value File April Release. 
 
Medicare guidance says 2021 National Physician Fee Schedule Relative Value File October Release. You can 
find this guidance in the Medicare Claims Processing Manual Chapter 26 - Completing and Processing Form 
CMS-1500 Data Set, 10.5 - Place of Service Codes (POS) and Definitions. 
 
Medicare guidance says 21 Inpatient Hospital; A facility, other than psychiatric, which primarily provides 
diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision 
of physicians to patients admitted for a variety of medical conditions. You can find the guidance in the 
Medicare Claims Processing Manual Chapter 26 - Completing and Processing Form CMS-1500 Data Set, 10.5 
- Place of Service Codes (POS) and Definitions. 
 
Medicare guidance says the work (or professional) component of physicians' services refers to the resources 
used in furnishing the service that reflect physician time and intensity. The technical component (or practice 
expense [PE]) refers to the portion of resources involved in furnishing services (such as equipment costs, office 
rent, and wages of personnel). As part of the CY 2021 Final Rule, CPT code 99153 was established as a PE-only code meaning there is no work component RVU associated with that service. The CY 2020 Final Rule 
established CPT codes 99151, 99152 and 99155-99157 as representative of the work component for moderate 
sedation services. This is further reflected in the 2021 National Physician Fee Schedule Relative Value File 
October Release with CPT code 99153 assigned a PC/TC indicator of 3 and a work RVU of 0.00. A medical 
necessity review was not completed as the denial was not for medical necessity. The plan is upholding the 
denial as the provider did not bill as required by Medicare coding regulations. You can find the guidance says 
CY Final Rule 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.