Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay forCPT 11721. We decided that the Plan does not have to pay forCPT 11055. You asked the Plan to pay forthe denied codes. You say that this should be paid for.The Plan says that the claim was submitted with CPT codes 11055 and 11721, which both require a Q modifier according to Medicare rules.We decided that the Planhas to pay forCPT 11721.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 CPT code 11721 is "Debridement of nail(s) by any method(s); 6 or more."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 for CPT 11721. Our reviewer says that the records support this code. Our physician reviewer found that Medicare guidelines advise that debridement of mycotic toenails is a covered service. The toenails in question must demonstrate clinical signs of onychomycosis as well as pain. The medical documentation dated 10/4/2019 advises that the enrollee demonstrates mycotic toenails 1-5 BL that are painful, thick, and ingrowing toenails.We looked at this physician's review, the file, and Medicare rules. CPT 11721 was not billed with a Q modifier, but there are medical circumstances which allow for the waiving of this coding requirement. Based on this information, we decided that Medicare rules for coverage of CPT 11721 have been met.Therefore, we decided that the Plan has to pay forCPT 11721.We also decided that the Plandoes not have to pay forCPT 11055.The Plan must follow Medicare rules. Medicare rules say that providers mustreport services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of CPT code 11055 is "Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion."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 for CPT 11055. Our reviewer says that the medical records do not support this code. Our physician reviewer found that Medicare guidelines advise that billing code 11055 (pairing of a corn or callous) may be covered if the patient demonstrates a systemic disease as well as certain risk factors (Q codes) that put the patient's foot at risk. In this particular case, the medical documentation does not advise that this enrollee is suffering with a systemic disease such as diabetes. Furthermore, the enrollee is noted to have diminished pedal pulses but intact neurologic sensation bilateral lower extremities (no evidence of neuropathy). The enrollee is noted to have a prior amputation of their second digit, however this does not meet Medicare coverage criteria for routine foot care as the patient does not demonstrate a systemic disease such as diabetes. Therefore,after careful review of the enclosed information and the pertinent guidelines for this case, it seems that the medical records do not support CPT 11055 on the date of service at issue in this case.We looked at this physician's review, the file, and Medicare rules. CPT 11055 was not billed with a Q modifier, and there are no medical exceptions found that would waive this coding requirement in this case. Based on this information, we decided that Medicare rules for coverage of CPT 11055 have not been met.Therefore, we decided that the Plan does not have to pay forCPT 11055.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 toreview. 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.