Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the office visit. We decided that the Plan does not have to pay for 
Meloxicam Injection, for Intravenous Use (AnjesoTM) (J3490), and injection of drug or substance under skin or 
into muscle (96372).  
 
You asked the Plan to pay the office visit. The Plan says that the office visit has been billed and paid. 
 
We decided that the Plan has to pay for an office visit (99212).  
 
The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent 
efforts to gather and forward information to the Independent Review Entity (IRE). You can find this 
information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Parts C & D Enrollee 
Grievances, Organization/Coverage Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
We looked at the file and the Medicare rules. The file shows that the Plan has not made reasonable and diligent 
efforts to gather and forward to us information regarding their decision to pay for the office visit. Specifically, 
the Plan has failed to forward any evidence that CPT code 99212 was previously billed, processed or paid. It is 
the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plans denial has not 
been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for an office 
visit (99212). 
 
We also decided that the Plan does not have to pay for Meloxicam Injection, for intravenous use 
(AnjesoTM) (J3490), and injection of drug or substance under skin or into muscle (96372). 
 
You asked the Plan to pay for Meloxicam Injection, for intravenous use (AnjesoTM) (J3490), and injection of 
drug or substance under skin or into muscle (96372). The Plan says Meloxicam Injection, for intravenous use 
(AnjesoTM) (J3490) has been handled under a different case, and injection of drug or substance under skin or 
into muscle (96372) does not meet the Medicare NCD coverage criteria and is non-covered. 
 
 The Plan follows Medicare rules. Medicare rules say that Medicare may cover a drug or biological if it is safe 
and effective and otherwise reasonable and necessary. Medicare rules say that for Medicare to consider 
coverage and payment for any item or service, the information submitted by the supplier or provider must 
corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage 
criteria have been met. 
 
We looked at the file and the Medicare rules. The documentation submitted does not include sufficient clinical 
information to verify if the billed injection was safe, effective and otherwise reasonable and necessary. 
Additionally, the NDC is listed on the claim as 73198005030. There is no record of this in the NDC database: 
https://www.accessdata.fda.gov/scripts/cder/ndc/dsp_searchresult.cfm. Therefore, we decided that the Plan 
does not have to pay for Meloxicam Injection, for Intravenous Use (AnjesoTM) (J3490), and injection of drug or 
substance under skin or into muscle (96372). 
 
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.