Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the removal of implanted material from the posterior segment of the 
eye (67121). We decided that the Plan does not have to pay for the removal of implanted material from the 
anterior segment of the eye (65920).  
 
You asked the Plan to pay for the removal of implanted material from the posterior segment of the eye (67121). 
You say that these codes are supported. The Plan says that there are more appropriate codes for the services 
performed. 
 
We decided that the Plan has to pay for the removal of implanted material from the posterior segment of the 
eye (67121).  
 
The Plan follows 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 67121 is removal of implanted material, posterior 
segment; intraocular. 
 
 
 
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 removal of implanted material from the  
posterior segment of the eye (67121). Our reviewer says that this code is supported. Our physician reviewer 
found the documentation states that active aspiration was used to remove the silicone oil from vitreous cavity 
completely. Repeated fluid air exchanges were carried out to release trapped silicone oil bubbles from ciliary 
processes. The oil was successfully removed. Documentation does not state Pars Plana Vitrectomy (PPV) was 
used. If oil is removed with aspiration, the correct code to report is CPT 67121. 
 
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 removal of implanted material from the  posterior segment of the eye 
(67121) have been met. Therefore, we decided that the Plan has to pay for the removal of implanted material 
from the posterior segment of the eye (67121).  
 
We also decided that the Plan does not have to pay for the removal of implanted material from the anterior 
segment of the eye (65920). 
 
The Plan follows 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 65920 is removal of implanted material, anterior segment 
of eye. 
 
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 removal of implanted material from the 
anterior segment of the eye (65920). Our reviewer says that this code is not supported. Our physician reviewer 
found the documentation is insufficient to verify CPT 65920-RT. 
 
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 removal of implanted material from the anterior segment of the eye (65920) 
have not been met. Therefore, we decided that the Plan does not have to pay for the removal of implanted 
material from the anterior segment of the eye (65920). 
 
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.