Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for direct therapeutic activities (97530) provided on February 15, 2023. 
We decided that the Plan does not have to pay for direct therapeutic activities (97530) provided on February 2, 
2023.  
 You asked the Plan to pay for direct therapeutic activities (97530) provided on February 2, 2023, and February 
15, 2023.. You say that this is supported in the records. The Plan says that the records do not support these 
services. 
 
We decided that the Plan has to pay for direct therapeutic activities (97530) provided on February 15, 
2023.  
 
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 code 97530 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We asked our physician reviewer 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 direct therapeutic activities (97530) provided 
on February 15, 2023. Our reviewer says that this code is supported for this date of service. Our physician 
reviewer found that the medical records document assessments of transfers and gait were performed along with 
pain assessments during ambulation and activity on February 15, 2023. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of direct therapeutic activities (97530) provided on February 15, 2023. have been 
met. Therefore, we decided that the Plan has to pay for direct therapeutic activities (97530) provided on 
February 15, 2023.  
 
We also decided that the Plan does not have to pay for direct therapeutic activities (97530) provided on 
February 2, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our physician reviewer 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 direct therapeutic activities (97530) provided 
on February 2, 2023. Our reviewer says that this code is not supported for this date of service. Our physician 
reviewer found that the records do not document any details of the therapeutic activities provided on February 
2, 2023. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of direct therapeutic activities (97530) provided on February 2, 2023. have not 
been met. Therefore, we decided that the Plan does not have to pay for direct therapeutic activities (97530) 
provided on February 2, 2023. 
 
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.