Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the surgical preparation or creation of the recipient site by excision 
(15002, 15003, 15004 and 15005) provided on April 3, 2020. 
 
You asked the Plan to pay for the surgical preparation. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that the documentation does 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 15002 is surgical preparation or creation of recipient site 
by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar 
contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children. 
 
The CPT Code Manual definition of code 15003 is surgical preparation or creation of recipient site by excision 
of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, 
trunk, arms, legs; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and 
children (List separately in addition to code for primary procedure). 
 
The CPT Code Manual definition of code 15004 is surgical preparation or creation of recipient site by excision 
of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, 
face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% 
of body area of infants and children. 
 
The CPT Code Manual definition of code 15005 is surgical preparation or creation of recipient site by excision 
of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, 
face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each additional 100 
sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to 
code for primary procedure). 
 
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 the surgical preparation. Our reviewers says that CPT codes 
15002, 15003, 15004 and 15005 meet criteria for billing and reimbursement consideration. Our reviewer found 
The operative report clearly documents excisional wound preparation. All of the areas were treated with the 
same procedure and measurements were taken to verify the correct CPT codes. 
 
 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical preparation have been met. Therefore, we decided that the Plan has 
to pay for the surgical preparation or creation of the recipient site by excision (15002, 15003, 15004 and 
15005) provided on April 3, 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.