Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay foradjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm (CPT Code 14301) and adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (CPT Code 14302) provided to the enrollee on March 28, 2018.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says the services are not supported.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 the services. Our reviewer says that [state physician reviewer's conclusion, e.g. "the service is not medically necessary." or "you need this medical item."] Our physician reviewer found Current Procedural Terminology (CPT) code 14301 -Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm and CPT 14302 -Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure) billed to the health plan for services provided on March 28, 2018 DOES NOT MEET CRITERIA for billing or reimbursement consideration. The medical records provided does not include document of specific square centimeter adjacent tissue transfer or rearrangement, therefore CPT 14301 and CPT 14302 are not eligible for reimbursement consideration. According to the National Correct Coding Initiative Policy Manual for CPT code 14301 and 14302, documentation should state the following; "The physician transfers or rearranges adjacent tissueof any area to repair traumatic or surgical wounds. This includes, but is not limited to, such rearrangement procedures as Z-plasty, W-plasty, ZY-plasty, or tissue transfers such as rotational flaps or advancement flaps. Report 14301 for defects 30.1 sq cm to 60 sq cm. Report 14302 for each additional 30 sq cm or part thereof. Report 14302 in 
addition to 14301. Report any skin grafts to close secondary defects separately. For an intralesional injection to limit scarring, see 11900." This description is notdocumented in the operative note. Medicare rules state, "For Medicare to consider coverage and payment for an item or service, the information submitted by the supplier or provider must corroborate the services so we can confirm Medicare coverage has beenmet." National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 1 states: "Physicians must report services correctly. There are certain types of improper coding that physicians must avoid. Procedures should be reported with the most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed."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 not been met.Therefore, we decided that the Plan does not have to pay foradjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm (CPT Code 14301) and adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (CPT Code 14302) provided to the enrollee on March 28, 2018.