Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97010, 97016, 97026, 97140, 97814, 99214 
and 99401 billed for date of service August 13, 2022. 
 
You asked the Plan to pay for procedure codes 97010, 97016, 97026, 97140, 97814, 99214 and 99401. You say 
that you have billed the services at issue correctly. The Plan denied your request. The Plan says the provided 
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 code 97016 is: Application of a modality to 1 or more areas; 
vasopneumatic devices. The definition of code 97140 is: Manual therapy techniques (eg, mobilization/ 
manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes. The definition 
of code 97814 is: Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of 
personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code 
for primary procedure). The definition of code 99214 is: 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. 
  
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 procedure codes 97016, 97140, 97814 and 99214. Our 
reviewer says that procedure codes 97016, 97140, 97814 and 99214 do not meet criteria for payment. Our 
reviewer found that procedure 97016 and 97140 have insufficient documentation to confirm these services 
were performed, as these procedures were not found in medical record for date of service billed. Per Healthcare 
plan, the primary procedure pertinent to procedure code 97814 was denied. In this case, as procedure 97814 is 
an "add-on" code for the denied primary procedure codes, procedure code 97814 would not be covered. 
Finally, the procedure report for the date of service at issue does not include sufficient documentation to verify 
an evaluation and management service coded 99214 has been performed. A brief history is documented; 
however, an exam and time spent is not 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 procedure codes 97016, 97140, 97814 and 99214 have not been met.  
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of 97010 have not been met. 
 
We find that procedure code 99401 has a status indicator of N on the Physician Fee Schedule. This means that 
procedure code 99401 is not covered by Medicare. Based on this information, we decided that Medicare rules 
for coverage of 99401 have not been met. 
 
Procedure code 97026 indicates infrared therapy services. The Medicare rules say that use of infrared and/or 
near-infrared light and/or heat, including monochromatic infrared energy, is non-covered. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 97010, 97016, 97026, 97140, 
97814, 99214 and 99401 billed for date of service August 13, 2022.