Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chemotherapy administration services coded 96413, the 
Intravenous infusion services coded 96367, the injection services coded 96375, the Carboplatin injection 
services coded J9045, the dexamethasone sodium phosphate injection services coded J1100, the ondansetron 
hydrochloride injection services coded J2405, and the magnesium sulfate injection services coded J3475 
provided from February 1, 2019 to February 15, 2019. 
 
You asked the Plan to pay for the chemotherapy administration services, the Intravenous infusion services, the 
injection services, the Carboplatin injection services, the dexamethasone sodium phosphate injection services, 
the ondansetron hydrochloride injection services, and the magnesium sulfate injection services. You say that 
you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services 
billed are not supported by the documentation. 
 
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 find that CPT codes 96413, 96367, 96375, J9045, J1100, J2405, and J3475 are not supported in the medical 
record. Specifically, the documentation submitted did not include documentation to support that chemotherapy 
administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug was performed on 
the billed date of service. Therefore, code 96413 cannot be verified. The required primary service 
code (CPT code 96413) is denied; therefore, code 96367 cannot be separately reimbursed. The required 
primary service code (CPT code 96413) is denied; therefore, code 96375 cannot be separately reimbursed. 
 
 
The documentation submitted did not include documentation to indicate that the Injection, carboplatin, 50 mg 
was administered on the billed date of service; therefore, code J9045 cannot be verified. The documentation 
submitted did not include documentation to indicate that the Injection, diphenhydramine HCl, up to50 mg was 
administered on the billed date of service; therefore, code J1200 cannot be verified. The documentation 
submitted did not include documentation to indicate that the Injection, dexamethasone sodium phosphate, 1 mg 
was administered on the billed date of service; therefore, code J1100 cannot be verified. 
The documentation submitted did not include documentation to indicate that the Injection, ondansetron HCl, 
per 1 mg was administered on the billed date of service; therefore, code J2405 cannot be verified. The 
documentation submitted did not include documentation to indicate that the Injection, magnesium sulfate, per 
500 mg was administered on the billed date of service; therefore, code J3475 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of the chemotherapy administration 
services, the Intravenous infusion services, the injection services, the Carboplatin injection services, the 
dexamethasone sodium phosphate injection services, the ondansetron hydrochloride injection services, and the 
magnesium sulfate injection services have not been met. Therefore, we decided that the Plan does not have to 
pay for the chemotherapy administration services coded 96413, the Intravenous infusion services coded 96367, 
the injection services coded 96375, the Carboplatin injection services coded J9045, the dexamethasone sodium 
phosphate injection services coded J1100, the ondansetron hydrochloride injection services coded J2405, and 
the magnesium sulfate injection services coded J3475 provided from February 1, 2019 to February 15, 2019.