Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forwheezing evaluation (94060), lung function test (94200), sinusoidal rotational test (92546), caloric vestibular test (92537) and a supplemental electrical test (92537) provided on July 3, 2019.You asked the Plan to pay forthe testing. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the services 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 CPT Code Manual definition of code 94060 is bronchodilation responsiveness, spirometry as in 94010, pre-and post-bronchodilator administration.The CPT Code Manual definition of code 94200 is maximum breathing capacity, maximal voluntary ventilation.The CPT Code Manual definition of code 92546 is Sinusoidal vertical axis rotational testing.The CPT Code Manual definition of code 92537 is Caloric vestibular test with recording, bilateral; bithermal (ie, one warm and one cool irrigation in each earfor a total of four irrigations).The CPT Code Manual definition of code 92547 is Use of vertical electrodes (List separately in addition to code for primary procedure).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 testing. Our reviewer says that CPT codes 94060, 94200, 92546, 92537 and 92547 do not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided does not include sufficient documentation to validate that Bronchodilation responsiveness, spirometry as in 94010, pre-and post-bronchodilator administration Bronchodilation 
responsiveness, spirometry as in 94010, pre-and post-bronchodilator administration was performed as a distinct, separate procedure on July 3, 2019 therefore this service cannot be verified. The medical records provided does not include sufficient documentation to validate that Maximum breathing capacity, maximal voluntary ventilation was performed as a distinct, separate procedure on July 3, 2019 therefore this service cannot be verified.The medical records provided does not include sufficient documentation to validate that Sinusoidal vertical axis rotational testing was performed as a distinct, separate procedure on July 3, 2019, therefore this service cannot be verified.The medical records provided does not include sufficient documentation to validate that Caloric vestibular test with recording, bilateral; bithermal (ie, one warm and one cool irrigation in each ear for a total of four irrigations) was performed as a distinct, separate procedure on July 3, 2019, therefore this service cannot be verified.The medical records provided does not include sufficient documentation to validate that Use of vertical electrodes (List separately in addition to code for primary procedure) was performed as a distinct, separate procedure on July 3, 2019, therefore this service cannot be verified.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 testing have not been met.Therefore, we decided that the Plan does not have to pay forwheezing evaluation (94060), lung function test (94200), sinusoidal rotational test (92546), caloric vestibular test (92537) and a supplemental electrical test (92537) provided on July 3, 2019