Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for an enterectomy (44120) provided on March 22, 2020. 
 
You asked the Plan to pay for an enterectomy. You say that this is documented in the record. The Plan denied 
your request. The Plan says that this code is 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. In this case, the CPT Code Manual definition of 
code 44120 is enterectomy, resection of small intestine; single resection and anastomosis. 
 
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 an enterectomy. Our reviewers says that the 
operative report dated March 22, 2020, supports CPT 44120. Our physician reviewer found to cite the operative 
report, "I then turned my attention back to the small bowel, which remained on the anterior abdominal surface 
covered and lap pads.  At this point, we did see some bile staining around portion of the small intestine.  This 
corresponded to the area that had been involved in the phlegmon using several clean lap pads) to a 60 cm 
segment of small bowel, which was probably the most inflamed section for the phlegmon.  After Careful 
evaluation, I was able to find a small pinpoint opening into the small intestine around the mesenteric border. I 
cannot see any signs of injury, and the hole itself was quite small but clearly was an area of leakage.  
Approximately 45 cm distal to this, I found a second similar area, pinpoint in size and on mesenteric border 
which also was an area of leakage. These areas had not been immediately visible, and they did not continuously 
leak, and only did so when placed under pressure. Fearing that other such areas might exist, I felt that resection 
of this entire inflamed segment was in the patient's best interest. I found the narrow segment of healthy bowel 
proximally and distally, which corresponded to approximately 65 cm of ileum to be resected.  I created a 
window in the mesentery, and used a GIA stapler to transect the bowel at both these locations. I dissected 
through the mesentery using a LigaSure impact to completely resect the segment in question. It was sent for 
specimen, and I brought the 2 segments of small bowel together.  I brought the 2 segments together in anatomic 
orientation, and proceeded to suture a Lembert back row for upcoming anastomsis. I then placed 2 anchoring 
sutures on the antimesenteric border and created an enterotomy of both the proximal and distal limb.  A GIA 
stapler was inserted into each limb of the enterotomy, and a side-to-side anastomosis was created. I closed the 
common enterotomy using a running full-thickness suture, which was then followed by an interrupted row of 
Lembert sutures. I tested the closure several times by passing the succus through the limbs, and no sign of 
leakage or air was noted. I then proceeded to sew an anterior running Lembert surure over the staple line.  
This resulted in a 360 degree oversewing of the anastomosis." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an enterectomy have been met. Therefore, we decided that the Plan has to pay 
for an enterectomy (44120) provided on March 22, 2020.  
 
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.