Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for J1745 and 99213. We decided that the Plan does not have to pay for 
J7050.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that fluids used 
to administer a drug are considered incidental hydration and are not separately payable. 
 
We decided that the Plan has to pay for J1745 and 99213.  
 
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 CPT Code Manual definition of 
the codes are: 
 
 
 Healthcare Common Procedure Coding System (HCPCS) J1745: 
 
Injection, infliximab, excludes biosimilar, 10 mg 
 
CPT 99213: 
 
Office or other outpatient visit for the evaluation and management of an established patient, which requires a 
medically appropriate history and/or examination and low level of medical decision making. When using time 
for code selection, 20-29 minutes of total time is spent on the date of the encounter 
 
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 for J1745 and 99213.  Our reviewer says that in terms 
of J1745, the provider clearly documents 660mg of Remicade infused, using 7 100mg vials, with 40mg of 
waste. Therefore, the procedure is verified and can be covered. In terms of CPT 99213, the documentation 
includes an evaluation and management service for this level of service and should be covered. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
J1745 and 99213.  
 
We also decided that the Plan does not have to pay for J7050. 
 
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 CPT Code Manual definition of 
HCPCS code J7050 is "Infusion, normal saline solution, 250 cc." 
 
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 for J7050. Our coding reviewer found that the 
documentation is not clear on if this procedure is being reported for hydration, which would be inclusive to 
drug administration. Therefore, this procedure code cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of J7050 have not been met. Therefore, we decided that the Plan does not have to 
pay for J7050. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.