Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on September 25, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain not supported.

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 denied codes is:

HCPCS A4222: 

Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately) 

HCPCS A4550: 

Surgical trays 

HCPCS A4556: 

Electrodes, (e.g., apnea monitor), per pair 

HCPCS A4557: 

Lead wires, (e.g., apnea monitor), per pair 

HCPCS A4624: 

Tracheal suction catheter, any type other than closed system, each 

HCPCS A7001: 

Canister, non-disposable, used with suction pump, each 

HCPCS A7002: 

Tubing, used with suction pump, each 

HCPCS A9901: 

DME delivery, set up, and/or dispensing service component of another 

HCPCS code HCPCS E0431: 

Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing 

HCPCS E0780: 

Ambulatory infusion pump, mechanical, reusable, for infusion less than 8 hours 

HCPCS E1390: 

Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate 

HCPCS E1399: 

Durable medical equipment, miscellaneous 

HCPCS J3490:

Unclassified drugs 

HCPCS S1015: 

IV tubing extension set 

HCPCS S8301: 

Infection control supplies, not otherwise specified 

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found A4222, A4624, A7001, A7002 and A9901 are not payable, as they are included in the payment for other services that were performed on the same date of service, on the same enrollee, by the same provider. The medical records submitted did not include an itemized shipping/billing invoice specific to the following codes/supplies - E0431, E0780, E1390, E1399, J3490. There was no proof of delivery. There was no documentation specifying the duration (start/stop) and dates for these supplies/drugs; therefore, the criteria for E0431, E0780, E1390, E1399 and J3490 was not met. A4550 has a status indicator of "B" and is always bundled into payment for other services. No separate payment is made by Medicare. A4556 and A4557 have a status indicator of "P" and are always bundled into payment for other services not specified. No separate payment is made by Medicare. S1015 and S8301 have a status indicator of "I" and are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for these codes. Therefore, S1015 and S8301 are not eligible for reimbursement. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on September 25, 2020.