Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a
Sanexas device reported on September 24, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You
say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan
says the record does not support that the procedures were performed as 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 HCPCS/CPT Code Manual
definition of code 97016 is application of blood vessel compression or decompression device to 1 or more
areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas;
electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is
therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code
99072 is additional supplies, materials, and clinical staff time over and above those usually included in an
office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by
law, due to respiratory-transmitted infectious disease. The HCPCS/CPT Code Manual definition of code 96372
is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.
The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code
Manual definition of code J3411 is injection, thiamine HCl, 100 mg. The HCPCS/CPT Code Manual definition
of code J3415 is injection, pyridoxine HCl, 100 mg. The HCPCS/CPT Code Manual definition of code J1955 is
injection, levocarnitine, per 1 gm.

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record.
Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer
of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the
criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was
applied to any area for any amount of time. The record states that the Sanexas device was applied using
standard programs. This does not support constant direct patient contact, which is required to report CPT code
97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed.
The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy
at the same time; the criteria for reporting CPT code 97150 has not been met.

Payment for CPT code 99072 is not supported. Specifically, CPT code 99072 has a status indicator of B and is
not recognized as a separately payable procedure.

Payment for HCPCS/CPT codes 96372, J3490, J3411, J1955, and J3415 are not supported. Specifically, the
record does not contain documentation of the dosage and type of drug administered in each injection, which is
required by Medicare for these services to be reimbursed.

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections
and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to
pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on September 24,
2020.