Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the muscle or tendon transfer (24301) provided September 3, 2020.

You asked the Plan to pay for the muscle or tendon transfer. You say that you would like this claim reprocessed for payment based on medical records supporting the code as billed. The Plan denied your request. The Plan says the requested service code is not substantiated by the clinical documentation in the medical records submitted for review.

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 24301 is muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331).

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 the muscle or tendon transfer. Our reviewer says that the medical records do not meet criteria for the billed code 24301. Our physician reviewer found that the medical records provided do not include sufficient documentation to validate that a muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331) was performed on September 3, 2020, therefore this service cannot be verified. Per the National Correct Coding Initiative Policy Manual regarding 24301, the physician performs a muscle or tendon transfer of the upper arm or elbow. An example is transfer of the latissimus dorsi muscle. This transfer restores active elbow flexion by transferring the origin and belly of the latissimus dorsi to the arm and anchoring the origin near the radial head. The patient is placed side lying with the affected side up. An incision is made starting at the loin and extending up to the axilla and distally along the medial aspect of the arm to the anterior elbow. The physician cuts free the origin of the latissimus dorsi. The muscle itself is cut free from the underlying abdominal muscles. The origin of the latissimus dorsi muscle is sutured to the biceps tendon and the periosteal tissues about the radial tuberosity. The incision is repaired in layers with sutures, staples, and/or Steri-strips. Tenoplasty with muscle transfer from the elbow to the shoulder should not be reported with 24301, instead see 24320. Flexor-plasty, elbow, also has more specific procedure codes and should be reported with 24330 or 24331. According to CPT guidelines, cast application or strapping (including removal) is only reported as a replacement procedure or when the cast application or strapping is an initial service performed without a restorative treatment or procedure. This description was not documented in the operative note to support the code as billed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the muscle or tendon transfer have not been met. Therefore, we decided that the Plan does not have to pay for the muscle or tendon transfer (24301) provided September 3, 2020.