Appeal type: Surgery
Decision: Favorable

We decided the Plan has to pay for surgery services (51595 and 55840) provided on December 14, 2021.
You asked the Plan to pay for this claim as billed. You say that this claim should be paid. The Plan denied your request. The Plan says that the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage of codes 51595 (Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis) and 55840 (Prostatectomy, retropubic radical, with or without nerve sparing). The Maximus Physician Reviewer determined that codes 51595 and 55840 meet criteria for billing and reimbursement consideration. The reviewer noted that both procedures were performed: radical cystectomy/ileal conduit/pelvic lymphadenectomy and radical prostatectomy. The Plan requested a reopen and argues that procedure code 51595-62-22 (Increased Procedural Services) is not supported by the medical records submitted.
The medical records show the enrollee is a 70-year-old man with diagnoses that included Carcinoma in situ of the bladder, Malignant neoplasm of overlapping sites of bladder, Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus, and a Personal history of irradiation. On December 14, 2021, the procedures included Cystectomy, complete, Ureteroileal conduit (ileal bladder), including intestine anastomosis (Bricker operation), with Physician standby service requiring prolonged attendance. Findings included radical cystoprostatectomy with bilateral pelvic lymph node dissection, extensive fibrosis on the anterior pelvis and on top of the ilial vessels from prior mesh. There was no evidence of rectal injury. Documentation included the following: "Midline incision was made from the pubic symphysis to just above the umbilicus. We entered through the fascia just superior to the pubic bone and bluntly dissected the space of Retzius. The peritoneal cavity was entered lateral the obliterated umbilical artery and the urachus controlled with the ligasure device. Inspection of the abdomen demonstated no evidence for disseminated disease or carcinomatosis. The bladder was mobilized by controlling the vas deferntia bilaterally at the level of the internal inguinal ring with the liagsure and the perioneum incised lateral to the lateral umbilical fold. The dissection was carried out to the level of the common iliac arteries to allow identification of the bilateral ureters. The pertinotomy was then extended in a cephalad direction along the course of the white lines of Toldt bilaerally. The ureteral were encircled with a vessel loop to aid in retraction and care was taken to ensure adequate ureteral adventitia was maintained during the dissection. The left and right ureters were then freed from their orthotopic bed through a combination of clips and bovie electrocautery and dissected to the level of the detrusor hiatus. As the lateral bladder pedicles were identified the obliterated umbilical artery was controlled with the ligature as were the remaining vessels of the lateral bladder pedicle. This allowed for the ureters to be controlled proximally with an O silk tie proximally and distally and transected. Bilateral ureteral margins were then sent and frozen section results are described above. The bowel was then retracted away with moist sponges and aided with the placemet of the Bookwalter retractor. The posterior dissection was then carried out by incising the peritoneum overlying the seminal vesicals at the dependent portion of the cul du sac. This peritonotomy was extended to obtain continuity with the previously incised lateral dissection.
The rectum was then carefully sharply dissected free from the posterior bladder and prostatic plane, maintaining denovilliers fascia with the bladder specimen. The dissection was carried out to the level of the prostatic apex. There was no inadvertent injury to the rectum. At this point we controlled the posterior vascular pedicles with the ligasure device, ensuring the rectum was protected from inadvertent transmission of heat or cautery. The apical dissection was then carried out by incising the endopelvic fascia bilaterally, sweeping the levator muscle off the lateral and apical aspects of the prostate. This allowed identification of the notch between the urethral and the dorsal venous complex which was controlled via suture ligature. The urethral was then identified and transected allowing the specimen to be extracted. Copious irrigation of the pelvis was performed, and residual bleeding controlled with 2-O and 3-O vicryl in an interrupted fashion. After ensuring excellent hemostasis, we turned our attention to the pelvic lymphadenectomy. The left and right dissection were performed by controlling the proximal and distal lymphatics with clips and perforating vessels with cautery. Care was taken to ensure the bilateral genitofemoral and obturator nerves were prospectively identified and uninjured. A complete dissection of the (common iliac; external iliac; obturator; hypogastric; presacral) lymph nodes was carried out and specimen sent for pathology. The Case was then handed off to an expert in urinary reconstruction. The left ureter had already been brought underneath the sigmoid mesentery to the right retroperitoneum. The tunnel was inspected and confirmed to be widely open so as not to compress, stretch, or kink the ureter. We then focused on the left retroperitoneum and proceeded to dissect the ureter superior up to the lower pole of the left kidney. When this was completed, we turned our attention to the right retroperitoneum and dissected the right ureter in similar fashion. The ureters were then retracted using the previously placed 2-0 ligatures. At that point, we began isolating a segment for the ileal conduit. The stomal site was located and the abdominal wall thickness was measured and found to be 14 cm. The distance from the left ureteral stump to the abdominal wall was measured and found to be 4 cm. These distances were added to determine the necessary length of the conduit which was 21 cm. The measuring tape was utilized to measure distance 15-20 centimeters from the ileocecal valve with emphasis on obtaining a maximally mobile location. The proximal and distal ends were marked with a 2-0 silk suture placed in a seromuscular fashion and the length of the conduit was approximately 21 cm. Mesentery was inspected for arcades and the distal mesentery was left along with this shorter mesentery on the proximal side. Once our sites were identified, mesentery was incised using Bovie electrocautery. The peritoneum was incised on both sides and LigaSure was used to seal the mesenteric vessels. Mesenteric fat was cleared from both our proximal and distal sites for harvesting the ileal conduit loop. Next, the GIA 75 stapler was used to transect the bowel, which was kept in an iso-peristaltic fashion, keeping the distal side for the stoma and the proximal side for the butt end. Once our segment was harvested, we restored the continuity of the bowel. The bowel was run proximally to ensure that it was free and the correct orientation. We aligned the distal and proximal ends of the bowel to perform a side-to-side anastomosis using a GIA 75 stapler along the antimesenteric sides of the bowel. This was crimped and a securing 2-0 silk stitch was placed in the crotch of side of the anastomosis and the stapler was deployed. Four Allis clamps were used to align the bowel, offsetting the staple line, and TA 60 was then deployed to complete the side-to-side anastomosis of the bowel. The internal lumen was palpable and found to be approximately 4-5 cm in diameter. The staple line was inverted with Lembert sutures all along the staple line of 3-0 silk sutures. Previously, the ileal segment to be used as the conduit was placed inferior to the intestinal anastomosis. It was inspected and noted to be correctly oriented. The mesenteric window was not closed. We turned our attention to the ileal conduit. The right and left ureters had been nicely mobilized and had good length on them. They were mildly hydrodistended. Next, we repositioned our retractor retracting the bowel cephalad as well as the anastomosis cephalad leaving our ileal conduit and our ureters in the field. A 3-0 silk suture was placed in the conduit as a retraction suture. We used 5-0 Vicryl to tack the left ureter first to the butt end towards the butt end of the conduit. The ureter was partially opened leaving the suture ligature in place as a "handle". The open lumen was then spatulated approximately 1.5 cm. A 5-0 Vicryl a holding stitch was placed. An enterotomy was made in the bowel using a stay suture and Bovie electrocautery. The ileal mucosa was everted using interrupted 5-0 Vicryl to allow for a mucosa-to-mucosa anastomosis. The ureter was spatulated and the anastomosis was performed with 5-0 Vicryl beginning with a stitch at the apex of the spatulation. Sequentially, 7 sutures were placed on each side of the spatulation in an interrupted fashion until the ureter was "anchored" to the bowel.
The staple line of the distal end of the harvested ileal segment was opened with electrocautery and 7-French x 90 cm diversion stent was passed retrograde into the kidney and the distal end placed through the bowel ostomy opening. The stent was secured to the ileal ostomy using a 5-0 chromic suture. The remainder of the anastomosis was performed in a running fashion using 5-0 Vicryl suture. The right ureter was similarly spatulated and the ureteroenteric anastomosis was performed in similar fashion. The right stent was secured to the urostomy opening in similar fashion. A Toomey syringe was utilized to test the ureteroenteric anastomosis for integrity. We then proceeded with forming our stoma at the newly planned site. The retractors were released and abdominal wall was inspected to ensure there was no bleeding, then the Bookwalter retractor was removed. At the site of the skin mark, a plunger of a 10 cc syringe was utilized to mark the skin and a plug of skin and adipose tissue was removed down to the fascia. A cruciate incision was performed in the fascia and 2-0 Vicryl sutures were placed at the apex of each fascial edge. The muscle was separated bluntly with a Kelly clamp and the peritoneum was scored and opened. A Babcock clamp was then utilized to translocate the ileal from the abdomen through the abdominal wall without tension. The mesentery of the conduit was reinspected and noted to appropriately oriented. We then proceeded with bowel eversion to create a "rose budd" opening for the conduit. Initially each 2-0 Vicryl suture in the fascial quadrants were placed through the ileal conduit 3-4 cm from the opening at the seromuscular level. These were then tied sequentially. Maturation sutures were dermis, bowel seromuscular layer, and out through the mucosa in the ostomy opening. 3-0- Vicryl sutures were placed sequentially in each quadrant to complete the maturation. The stents were secured to the skin at the 9 o'clock position utilizing a 2-0 silk suture. A 16-French red rubber catheter was placed and also secured to the skin with 2-0 silk. The stents and red rubber catheter were placed in a free glove and clamped to the site of the drape. The pelvis was then irrigated with antibiotic solution. Once hemostasis was obtained, attention was turned to closure of the fascia. A 19 French round Blake drain was placed through the skin, abodminal wall, and into the pelvis. This is secured to the skin with a 3-0 Nylon suture. Exparel was injected into the fascia and preperitoneal spaces along the incision and around the conduit site, 20cc diluted to 100cc was injected in the preperitoneal/tranversalis and subdermal spaces. The fascia is closed with a running looped 0 PDS suture. One suture is run from the inferior edge of the incision to midportion, and a second suture is run from the superior edge to the midportion. The sutures are then tied together. Additionally, after every third fascial stitch, # 2 Vicryl retention sutures were placed through the fascia in figure-of-eight fashion. The wound is copiously irrigated. The subcutaneous layers are closed with 3-0 Vicryl suture placed in an interrupted fashion to close the dead space of these layers. A subcutaneous drain was not left in place. The skin was approximated with 4-0 Monocryl subcuticular. The wound is cleaned with wet and then dry lap sponges. A sterile surgical dressing is then applied. An ostomy bag is sized correctly and placed over the ostomy site with the stents and catheter inside the bag." Our Medical Director has concluded that this appears to be a difference of opinion among medical experts. Determinations of medical necessity by Maximus physician reviewers are tailored to the individual patient and their unique clinical scenario. In this case, a Maximus Physician Reviewer, with appropriate expertise and qualifications, rendered an unbiased and well-considered opinion. The medical review was appropriate and well-supported by documentation in the case file. Thoughtful, qualified experts can and often do, disagree about interpretations of case file evidence and its application to coverage determinations. The fact that the health plan disagrees with our expert's opinion is not in itself sufficient grounds for reversing the determination in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this claim as billed have been met. Therefore, we decided that the Plan has to pay for surgery services (51595 and 55840) provided to the enrollee on December 14, 2021.