Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97813, 97814, 97140, 97110, 97139, 
G0283, 97016, 97039, and 99214 billed for date of service June 16, 2023. 
 
You asked the Plan to pay for 97813, 97814, 97140, 97110, 97139, G0283, 97016, 97039, and 99214. You say 
that 97813, 97814, 97140, 97110, 97139, G0283, 97016, 97039, and 99214 should be paid as billed because 
they are supported in the medical record. The Plan denied your request. The Plan says 97813, 97814, 97140, 
97110, 97139, G0283, 97016, and 97039 are denied because they are not supported in the documentation. 
99214 is denied because it is considered bundled into payment for code 97813. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The also rules say that acupuncture services are 
not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited 
coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day 
period, and no more than 20 sessions per year. 
 
In this case, the CPT Code Manual definition of code 97813 is acupuncture, 1 or more needles; with electrical 
stimulation, initial 15 minutes of personal one-on-one contact with the patient. 
 
The CPT Code Manual definition of code 97814 is acupuncture, 1 or more needles; with electrical stimulation, 
each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (list 
separately in addition to code for primary procedure). 
 
The CPT Code Manual definition of code 97140 is manual therapy techniques (for example, mobilization/ 
manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes. 
 
The CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; 
therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
We looked at the file and Medicare rules. We find that CPT codes 97813, 97814, 97140, and 97110 are not 
supported in the medical record. Specifically, the code definition for each is time-based, and the records 
submitted for review do not document the total time spent providing the services described by these codes. 
Regarding codes 97139, G0283, 97016, and 97039, Medicare coverage for acupuncture services is limited to 
acupuncture codes only for the treatment of CLBP. Codes 97139, G0283, 97016, and 97039 describe non-
acupuncture services, therefore, they would not be covered under the acupuncture benefit and records in this 
case indicate that they were performed by a licensed acupuncturist rather than a physician, physician assistant, 
nurse practitioner, or clinical nurse specialist. Records also do not indicate these services were performed under 
supervision of a physician, physician assistant, nurse practitioner, or clinical nurse specialist. Regarding code 
99214, we have confirmed that code 99214 is a column II code to column I code 97813. This claim has not 
been billed with an appropriate modifier to bypass the edit. Based on this information, we decided that 
Medicare rules for coverage of 97813, 97814, 97140, 97110, 97139, G0283, 97016, 97039, and 99214 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 97813, 97814, 97140, 
97110, 97139, G0283, 97016, 97039, and 99214 billed for date of service June 16, 2023.