Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for CPT code 42335. We decided that the Plan does not have to pay for CPT code 42505. You asked the Plan to pay for CPT codes 42505 and 42335. You say that the medical records provided support the CPT codes in dispute.The Plan says that the submitted medical records do not indicate that the services represented by the CPT codes billed were supplied on the date of service in dispute. The Plan says that the billed services cannot be verified.We decided that the Planhas to pay forCPT code 42335.The Plan follows Medicare rules. Medicare rules say that procedures should be reported with the CPT code that describes the service performed. Medicare rules also say that providers must furnish sufficient information to determine whether payment is due and the amount of payment.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 CPT code 42335. Our reviewer says that the criteria for coverage have been met. The definition of CPT code 42335 is sialolithotomy; submandibular, complicated, intraoral. Our physician reviewer found that the operative note clearly provides documentation that CPT code 42335 was performed. Two stones were removed from the gland through an intraoral incision. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 42335 have been met.Therefore, we decided that the Plan has to pay forCPT code 42335. We also decided that thePlandoes not have to pay forCPT code 42505.The Plan follows Medicare rules. Medicare rules say that procedures should be reported with the CPT code that describes the service performed. Medicare rules also say that providers must furnish sufficient information to determine whether payment is due and the amount of payment. 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 CPT code 42505. Our reviewer says that the criteria for coverage have not been met. The definition of CPT code 42505 is plastic repair of salivary duct, sialodochoplasty; secondary or complicated. Our physician reviewer found that the clinical documentation should state that the provider "passes a tube made of a material like polyethylene into the duct of the salivary gland in the mouth. He passes the tube through the duct. Repair of the duct is further complicated by extensive salivary gland pathology. He leaves the tube in place, possibly secured with sutures. Our physician reviewer found that the operative note does not provide documentation that CPT code 42505 was performed. 42505 should include the provider passing a tube in order to help repair the duct. Also, there should be documentation as to why the repair was complicated. The operative note does not state that a tube was used, nor does it state why the repair was complex.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 42505 have not been met.Therefore, we decided that the Plan does not have to pay forCPT code 42505.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.