Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe intravenous infusion (96365, 96366), injection (96375), diphenhydramine and immune globulin provided on May 29, 2020.You asked the Plan to pay forthe infusion and injections. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that the documentation submitted does not support the service 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. 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 infusion and injections. Our reviewers saythat These services meet criteria for billing and reimbursement consideration. Based on Additional Information submitted by the provider, the medical records do include documentation that Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour was started at 10:16 am and was stopped at 12:30 pm which corroborates CPT code 96365 was performed and meets Medicare criteria. Also Current Procedural Terminology (CPT) code 96366 meets criteria as the Additional Information provided indicates in the medical record the Intravenous infusion started at 10:16 am extended beyond 1 hour and ended at 12:30 pm meeting coding definition for CPT 96366. The Additional Information provided indicates in the medical record that benadryl / diphenhydrAMINE 25 mg was injected at 10:10 am and validates CPT code 96375 was provided and meets Medicare requirements. Our reviewer found the Additional Information provided indicates in the medical record that benadryl / diphenhydrAMINE 25 mg was injected at 10:10 am and validates Injection, diphenhydramine hcl, up to 50 mg was performed and meets Medicare requirements. The Additional Information provided indicates in the medical record that 40g of Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg was administered to the patient via Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour and Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) from 10:16 am until 12:30 pm on May 29, 2020 and meets Medicare criteria.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 infusion and injections have been met.Therefore, wedecided that the Plan has to pay forthe intravenous infusion (96365, 96366), injection (96375), diphenhydramine and immune globulin provided on May 29, 2020.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.