Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the safety equipment. We decided that the Plan does not have to pay for the drugs, tubing extension and infection control supplies.
You asked the Plan to pay for the drugs and supplies. You say that you would like reconsideration based on the records submitted. The Plan says that the documentation submitted does not support the services billed.
We decided that the Plan has to pay for the safety equipment. The Plan follows Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. 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 drugs and supplies. Our coder found CPT code E0700 meets criteria for billing and reimbursement consideration. The documentation submitted supports that this service was rendered in an outpatient setting. The anesthesia was supplied by an outside company.
Our reviewer says that CPT code J3490 does not meet criteria for billing or reimbursement consideration because the record does not indicate that unclassified drugs were administered. CPT codes S1015 and S8301 do not meet criteria for billing or reimbursement consideration because per the Physician Fee Schedule, these codes have a status code of I. This means that these codes are not valid for Medicare purposes. Our coder found CPT code E0700 meets criteria for billing and reimbursement consideration. The documentation submitted supports that this service was rendered in an outpatient setting. The anesthesia was supplied by an outside company. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of safety equipment have been met. Therefore, we decided that the Plan has to pay for the safety equipment.
We also decided that the Plan does not have to pay for the drugs, tubing extension and infection control supplies. "The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 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 drugs, tubing extension and infection control supplies. Our reviewer says that CPT code J3490 does not meet criteria for billing or reimbursement consideration because the record does not indicate that unclassified drugs were administered. CPT codes S1015 and S8301 do not meet criteria for billing or reimbursement consideration because per the Physician Fee Schedule, these codes have a status code of I. This means that these codes are not valid for Medicare purposes. 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 drugs, tubing extension and infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for the drugs, tubing extension and infection control supplies.