Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96360, 96365, 96367, 96368, 96375, 99215, 
and J3490 rendered on October 18, 2022. 
 
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: 
 
CPT 96360: 
 
Intravenous infusion, hydration; initial, 31 minutes to 1 hour  
CPT 96365: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour 
 
CPT 96367: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential 
infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure) 
 
CPT 96368: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion 
(List separately in addition to code for primary procedure) 
 
CPT 96375: 
 
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential 
intravenous push of a new substance/drug (List separately in addition to code for primary procedure) 
 
CPT 99215: 
 
Office or other outpatient visit for the evaluation and management of an established patient, which requires a 
medically appropriate history and/or examination and high level of medical decision making. When using time 
for code selection, 40-54 minutes of total time is spent on the date of the encounter. 
 
CPT J3490: 
 
Unclassified drugs 
 
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 that the procedure report includes 
documentation of intravenous hydration infusion therapy, however, the provider reported intravenous infusion 
for therapy, prophylaxis which would include hydration infusion. Therefore, CPT 96360 cannot be verified. 
 
In terms of CPT 96365, 96367, 96368, and 93675, the procedure report does not include documentation of 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour, or 
additional sequential fusion, concurrent infusion, or each additional sequential push of a new substance/drug. 
Therefore, these codes cannot be verified. 
 
In terms of CPT 99215, the time spent for this procedure was for 30 minutes, and therefore does not meet the 
coding criteria.  
 
Finally, in terms of J3490, the medical records do not include sufficient documentation to verify an unclassified 
drug. This code cannot be verified. 
 
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 procedure codes 96360, 96365, 96367, 96368, 96375, 99215, and J3490 rendered on October 
18, 2022.