Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora therapeutic, prophylactic, or diagnostic injection (96375), chemo administration (96415), IV infusion (96367), ranitidine hydrochloride (J2780) and diphenhydramine hcl (J1200) provided on October 23, 2019.You asked the Plan to pay for the injections. 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.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 injections. Our reviewer says that CPT code 96375 does not meet criteria for billing or reimbursement consideration. The medical record provided does not include a flow sheet to validate that 2 units of Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) was performed on October 23, 2019, therefore this service cannot be verified. CPT code 96415 does not meet criteria for billing or reimbursement consideration. The medical records provided does not include a start and stop time to corroborate an additional hour of Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure), therefore this service cannot be verified.CPT code 96367 does not meet criteria for billing or reimbursement consideration. he medical records provided does not include documentation to validate that an intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug);additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure) was performed on October 23, 2019, therefore this service cannot be verified. Our reviewer found CPT code J2780x2 does not meet criteria for billing or reimbursement consideration. The medical records provided do not include documentation to validate that an Injection, ranitidine hydrochloride, 25 mg was performed on October 25, 2019, therefore this service cannot be verified.CPT code J1200 does not meet criteria for billing or reimbursement consideration. The medical records provided does not include documentation to validate that an Injection, diphenhydramine hcl, up to 50 mg was performed on October 23, 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 injections have not been met.Therefore, we decided that the Plan does not have to pay fora therapeutic, prophylactic, or diagnostic injection (96375), chemo administration (96415), IV infusion (96367), ranitidine hydrochloride (J2780) and diphenhydramine hcl (J1200) provided on October 23, 2019.