Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for CPT code 50820. We decided that the Plan does not have to pay for 
CPT code 52332.  
 
You asked the Plan to pay for CPT codes 50820 and 52332. You say that the medical records support the 
billing of CPT codes 50820 and 52332. The Plan says that the medical records do not support the billing of 
CPT codes 50820 and 52332. 
 
We decided that the Plan has to pay for CPT code 50820.  
 
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 50820 is Ureteroileal conduit (ileal bladder), including intestine anastomosis (Bricker operation). 
 
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 50820. Our reviewer says that the 
medical records support the billing of CPT code 50820. Our physician reviewer found the enrollee is with 
invasive colon cancer involving the bladder. She underwent robotic cystectomy, low anterior resection, partial 
vaginectomy and bilateral ureteral stent placement on April 7, 2020. The medical records provided do support 
the billing of CPT code 50820.  
 
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 50820 have been met. Therefore, we decided that the Plan has to pay 
for CPT code 50820.  
 
We also decided that the Plan does not have to pay for CPT code 52332. 
 
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 52332 is Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type). 
 
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 52332. Our reviewer says that the 
medical records do not support the billing of CPT code 52332. Our physician reviewer found the enrollee is 
with invasive colon cancer involving the bladder. She underwent robotic cystectomy, low anterior resection, 
partial vaginectomy and bilateral ureteral stent placement on April 7, 2020. The medical records do not support 
the billing of CPT code 52332. There is another code that Medicare uses for the placement of stents during a 
cysetectomy or other abdominal surgical procedure when an incision is made in a ureter. 
 
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 52332 have not been met. Therefore, we decided that the Plan does 
not have to pay for CPT code 52332. 
 
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.