Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided on March 19, 2020, billed with
codes 21198, 31225, 35701, 38724, and 43752.
You asked the Plan to pay for the surgical procedures as billed. You say that the services were billed correctly
and should be paid. The Plan denied your request. The Plan says only a few of the billed codes are supported
by the record.
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 21198 is Osteotomy, mandible, segmental. The definition
of 31225 is Maxillectomy; without orbital exenteration.
The definition of 42752 is Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic
guidance (includes fluoroscopy, image documentation and report). The definition of 35701 is Exploration not
followed by surgical repair, artery; neck (eg, carotid, subclavian. The definition of 38724 is Cervical
lymphadenectomy (modified radical neck dissection).
We asked our coder 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 procedures as billed. Our reviewer says that the
report does not support the use of these codes to describe the services rendered. Our reviewer found the
surgical services were provided to treat squamous cell carcinoma of the mouth. Code 21198 is not supported as
the operative report makes no mention of mandibular osteotomy. For 31225, the operative report states:
"Careful dissection was then performed along the maxilla with removal of the mucosa from the maxillary
alveolar ridge as well as the hard palate as well as removal some of the bone using a cutting bur."
Maxillectomy is to remove a primary tumor in this area. This involves removing some of the bone in the
maxilla, part of the roof of the mouth, and possible teeth. This was not documented in the operative report. For
43752, the operative report does not include enough detail to confirm fluoroscopic guidance image
documentation and report. Therefore, this procedure cannot be confirmed. For 35701, the report does not
include documentation of artery exploration not followed by repair. To cite the report "Attention was then
turned to the carotid system which was carefully dissected superiorly. The superior thyroid, lingual, and facial
nerve branches were carefully dissected free the facial artery was carefully preserved mobilized and chosen to
serve as the vessel for the flap. A facial vein was also carefully mobilized and preserved. The external jugular
vein was kept also". Lastly, code 38724 is not supported because the report does not document the removal of
one of more groups of lymph nodes.
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 procedures as billed have not been met. Therefore, we decided that
the Plan does not have to pay for the surgical services provided on March 19, 2020, billed with codes 21198,
31225, 35701, 38724, and 43752.