Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) G0378, 70496, 70498, and 
70450. We decided that the Plan does not have to pay for the services described by procedure code(s) 93005, 
96360, 96361, A4556, and A4649.  
 
You asked the Plan to pay for testing services provided on September 23, 2022. You say that the claim is billed 
correctly and should be paid. The Plan says that codes 93005, 96360, and 96361 are billed with an invalid place 
of service. Codes A4556 and A4649 are bundled and not separately payable. 
 
We decided that the Plan has to pay for the services described by procedure code(s) G0378, 70496, 
70498, and 70450.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) G0378, 70496, 70498, and 
70450.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
93005, 96360, 96361, A4556, and A4649. 
 
The Plan follows Medicare rules. Medicare rules say that the TC of radiology and other diagnostic services 
furnished to hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the 
hospital. The rules also say that if an item or service is covered as incident to a physician service and is 
provided on the same day as a physician service, payment for it is bundled into the payment for the physician 
service to which it is incident.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 93005, 96360, 96361, A4556, and A4649 have not 
been met. Procedure codes 93005, 96360, and 96361 are technical components and are not payable in the 
facility setting. Codes A4556 and A4649 have a status indicator of P and are not separately payable. Therefore, 
we decided that the Plan does not have to pay for the services described by procedure code(s) 93005, 96360, 
96361, A4556, and A4649. 
 
 
 
 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.