Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedure, 1 or more areas, each 15 minutes; 
neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or 
proprioception for sitting and/or standing activities (97112 GO 59 (2 units)) and therapeutic activities, direct 
(one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes 
(97530 GO 59 (2 units)) provided from May 13, 2020, through May 18, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 physician reviewer 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 services. Our physician reviewer found 
the review has determined that Current Procedural Terminology (CPT) code 97530 GO 59 (2 units) remains 
not supported. The submitted medical records do not indicate that therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes was performed. 
Therefore, the billed Current Procedural Terminology (CPT) code, modifiers and units cannot be verified. Of 
note, a unit of time is required to bill this code. It is noted that multiple attempts were made to contact the 
provider for additional information. Current Procedural Terminology (CPT) code 97530 GO 59 (2 units) 
remains not supported. The submitted medical records do not indicate that therapeutic activities, direct (one-on-
one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes was 
performed. Therefore, the billed Current Procedural Terminology (CPT) code, modifiers and units cannot be 
 
 
verified. Of note, a unit of time is required to bill this code. It is noted that multiple attempts were made to 
contact the provider for additional information. Current Procedural Terminology (CPT) code 97112 GO 59 (2 
units) remains not supported. The submitted medical records do not indicate that therapeutic procedure, 1 or 
more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic 
sense, posture, and/or proprioception for sitting and/or standing activities was performed. 
The review has determined that the services are not supported in the medical records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of 
movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing 
activities (97112 GO 59 (2 units)) and therapeutic activities, direct (one-on-one) patient contact (use of 
dynamic activities to improve functional performance), each 15 minutes (97530 GO 59 (2 units)) provided 
from May 13, 2020, through May 18, 2020.