Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for J2001 and 76942. We decided that the Plan does not have to pay for 
76881 and 99214.  
 
You asked the Plan to pay for procedure codes 76881, 76942, 99214, and J2001 rendered on March 17, 2023.. 
You say that this should be paid for. The Plan says that the records do not support the services billed. 
 The definition of the denied codes is: 
 
CPT 76881: 
 
Ultrasound, complete joint (ie, joint space and peri-articular soft-tissue structures), real-time with image 
documentation 
 
CPT 76942: 
 
Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging 
supervision and interpretation 
 
CPT 99214: 
 
Office or other outpatient visit for the evaluation and management of an established patient, which requires a 
medically appropriate history and/or examination and moderate level of medical decision making. When using 
time for code selection, 30-39 minutes of total time is spent on the date of the encounter 
 
Healthcare Common Procedure Coding System (HCPCS) J2001: 
 
Injection, lidocaine hcl for intravenous infusion, 10 mg 
 
We decided that the Plan has to pay for J2001 and 76942.  
 
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 for CPT J2001 and CPT 76942. Our reviewer says that 
J2001 is equivalent to a Lidocaine injection and should be approved as documented in the records. In terms of 
CPT 76942, this corresponds to an ultrasound-guided aspiration of the right knee. This was appropriately 
documented in the records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
J2001 and 76942.  
 
We also decided that the Plan does not have to pay for 76881 and 99214. 
 
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 for CPT 76881 and CPT 99214. Our reviewer says that 
in terms of CPT 76881, a more appropriate would have been CPT 76882. The only finding described was a 
joint effusion with no comment on the surrounding soft tissues. In terms of CPT 99214, this corresponds to 30-
39 minutes of face time. The procedure note does not document the total time spent. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 76881 and 99214 have not been met. Therefore, we decided that the Plan does 
not have to pay for 76881 and 99214. 
 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.