Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes J7030, 36000, 99070, 99072, 3028F, 
A4615, A4930, 93040, and 93790 rendered on May 11, 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 records do not support the services billed. 
 
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: 
 
Healthcare Common Procedure Coding System (HCPCS) J7030: 
 
Infusion, normal saline solution , 1000 cc 
 
CPT 36000: 
 
Introduction of needle or intracatheter, vein 
 
CPT 93040: 
 
Rhythm ECG, 1-3 leads; with interpretation and report 
 
CPT 93790: 
 
Ambulatory blood pressure monitoring, utilizing report-generating software, automated, worn continuously for 
24 hours or longer; review with interpretation and report 
 
CPT 3028F: 
 
Oxygen saturation results documented and reviewed (includes assessment through pulse oximetry or arterial 
blood gas measurement) (CAP, COPD) (EM) 
 
HCPCS A4615: 
 
Cannula, nasal 
 
HCPCS A4930: 
 
Gloves, sterile, per pair 
 
CPT 99070: 
 
Supplies and materials (except spectacles), provided by the physician or other qualified health care professional 
over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, 
or materials provided) 
 
CPT 99072: 
 
Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or 
other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to 
respiratory-transmitted infectious disease 
 
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 for CPT 93040 and CPT 93790. Our reviewer says that these codes 
were not supported by the medical records. Our reviewer found that in terms of CPT 93040, the provided 
performed a service which would require cardiopulmonary monitoring. In this case, this procedure would not 
be reported separately and is not supported in the records. In terms of CPT 93790, the procedure report does 
not include documentation to support ambulatory blood pressure, utilizing report-generating software, 
automated, worn continuously for 24 hours or longer, review with interpretation and report. In this procedure, 
the provider prescribes ambulatory blood pressure monitoring in which a patient wears a device continuously 
that automatically measures blood pressure at intervals over 24 hours and records the results. The provider 
interprets the data and reports his findings. This was not found in the records. 
 
Additionally, J7030 is not supported, as it has a status indicator of E. This indicates that the code is excluded 
from coverage. 
 
Codes 36000, 99070, and 99072 have a status indicator of B. This indicates that payment for these codes is 
always bundled into payment for other services. It is not appropriate to report these services separately. 
 
3028F has a status indicator of I. This indicates that this code is invalid to be used for Medicare purposes. 
 
Finally, A4615 and A4930 have a status indicator of X. This indicates that these codes are a statutory exclusion 
and should not be billed. 
 
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 J7030, 36000, 99070, 99072, 3028F, A4615, A4930, 93040, and 93790 
rendered on May 11, 2022.