Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services (96365-59, 96366-59, 96521 and J1817) 
provided March 30, 2023. 
 
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services are not supported and there are more appropriate codes that 
should be used. 
 
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 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). The definition of code 96521 is refilling and maintenance 
of portable pump. The definition of code J1817 is insulin for administration through durable medical 
equipment (DME) (i.e., insulin pump) per 50 units. 
 
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 found for code 96365, the 
documentation submitted was reviewed and does not meet criteria. The medical record includes documentation 
to support intravenous infusion treatment provided for an outpatient. In this case, there is a more specific 
Healthcare Common Procedure Coding System (HCPCS) code that should be reported for service documented. 
The procedure code billed, does not support service documented and therefore, cannot be verified. 
 
For code 96366, the documentation submitted was reviewed and does not meet criteria. The medical record 
includes documentation to support intravenous infusion treatment provided for an outpatient. In this case, there 
is a more specific HCPCS code that should be reported for service documented. The procedure code billed, 
does not support service documented and therefore, cannot be verified. 
 
For code 96521, the documentation submitted was reviewed and does not meet criteria. The medical record 
includes a physician order for refilling and maintenance or portable pump; however, the medical record does 
not support procedure was performed, and therefore, cannot be verified. 
 
For code J1817, the documentation submitted was reviewed and does not meet criteria. The medical record 
includes documentation to support intravenous infusion treatment provided for an outpatient. In this case, there 
is a more specific HCPCS code that should be reported for service documented. The procedure code billed, 
does not support service documented and therefore, 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 the medical services (96365-59, 96366-59, 96521 and J1817) provided March 30, 2023.