Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic, prophylactic, or diagnostic injection (specify 
substance or drug); subcutaneous or intramuscular (CPT code 96372), application of a modality to 1 or more 
areas; vasopneumatic devices (CPT code 97016-GP), unclassified drugs (CPT code J3490 X 3), and physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 
minutes (97750-GP) provided to the enrollee on April 26, 2021. 
 
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 Medicare rules say a TENS device including supplies is not a Medicare covered benefit 
with the available information. The Plan states pneumatic compression vasopneumatic devices can be covered 
in the home or other outpatient setting only for the treatment of chronic venous insufficiency with venous stasis 
ulcers, and refractory lymphedema. The Plan states vitamin injections into the nerve and musculoskeletal 
structures are not a Medicare-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Review of the file shows that the CPT codes with modifier of GP were rendered by a nurse practitioner and are 
not covered. Unless the provider is a licensed therapist, Medicare does not cover these therapy services. The 
rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or 
under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a 
nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy 
services under State law. You can find this information in Title 42 CFR Section 410.60. 
 
Review of the file shows that the Plan was handling CPT code J3490 separately; however, there was no 
specific statement in the appeal letter saying that only a subset of the codes is being appealed. Therefore, we 
are making a decision on this code as well. We are upholding the denial on the compounded drugs, because 
they need to be billed with one unit of the 'not otherwise specified drug code'. The rules say that beginning in 
July 2015, claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified 
(NOC) code. You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only 
Manual, Medicare Claims Processing Manual, Chapter 17, Section 20.1.2. 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, prophylactic, or diagnostic injection (specify substance or drug); 
subcutaneous or intramuscular (CPT code 96372), application of a modality to 1 or more areas; vasopneumatic 
devices (CPT code 97016-GP), unclassified drugs (CPT code J3490 X 3), and physical performance test or 
measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes (97750-GP) 
provided to the enrollee on April 26, 2021.