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 July 6, 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 97112 is 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. 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.

We find that HCPCS/CPT codes 97016, 97032, and 97112 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 a therapeutic procedure for neuromuscular reeducation for sitting or standing activities was performed. There is no mention of therapy to perform these functions; the stimulation provided by the Sanexas device does not satisfy the requirements to report CPT code 97112.

Payment for HCPCS/CPT codes 96372, J3490, J3411, 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 July 6, 2020.