Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the fasciocutaneous flap procedure with recipient site prep and local tissue rearrangement provided on August 24, 2020, billed with codes 15733, 15004, and 14041.

You asked the Plan to pay for the surgical services as billed. You say that this was correctly billed and should be paid as the services were medically necessary. The Plan denied your request. The Plan says the codes used for this procedure were 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 15733 is Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae).

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 14041 is Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm.

We asked our coding 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 the surgical services as billed. Our reviewer says that the documentation does not support the codes used to describe this procedure. Our coding reviewer found the operative report does not document the procedure of preparation or creation of recipient site; therefore, code 15004 cannot be confirmed as performed. Operative report supports a complex repair, rather than adjacent tissue transfer due to undermining; therefore, code 14041 is not supported by the operative report.

For CPT 15733, operative report does support this procedure. Procedure report documents "An inferiorly based nasolabial flap was marked in order to properly reconstruct the defect making sure that it was long enough to reach the lower part of the ala and the side wall nose defect, but no give the patient any flaring of the nostrils due to tension. Then, using a 15 blade followed by sharp and blunt dissection, the flap was elevated down to the nasal bone and cartilage, at the same time I brought up the nasolabial flap with the pedicle well protected. The flap was elevated making sure to identify and protect the angular artery and vein and freeing the pedicle for the flap to advance and rotate without placing tension on the vessels. The edges of the defect were undermined as well sharply, and the defect wound was cleaned and prepared for the flap to be transferred by sharply dissecting away ischemic tissue. Bipolar cautery was utilized to obtain hemostasis". This does not support the services described by 15733.

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 services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the fasciocutaneous flap procedure with recipient site prep and local tissue rearrangement provided on August 24, 2020, billed with codes 15733, 15004, and 14041.