Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the Application of skin substitute graft (15275 and 15276) provided on 
March 29, 2021. 
 
You asked the Plan to pay for codes 15275 and 15276. You say that the medical records support the billing of 
codes 15275 and 15276 provided on March 29, 2021. The Plan denied your request. The Plan says that the 
medical records do not support the billing of codes 15275 and 15276 provided on March 29, 2021. 
 
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 15275 is Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, 
hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound 
surface area. The definition of code 15276 is Application of skin substitute graft to face, scalp, eyelids, mouth, 
neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each 
additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary 
procedure). 
 
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 codes 15275 and 15276. Our reviewer says that the medical 
records support the billing of codes 15275 and 15276 provided on March 29, 2021. Our reviewer found after 
careful review of the enclosed information and the pertinent guidelines for this case, the medical records do 
indeed support the billing of code 15275 provided on March 29, 2021.  It is well established in the medical 
documentation that this enrollee is suffering with multiple ulcerations to their left foot.  During this visit it is 
documented that the ulcerations were debrided to full thickness and Grafix prime was applied to the wounds. 
Code 15275 is application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, 
hands, feet and or multiple digits, total wound service up to 100 cm2: first 25 cm2. The wound sizes are noted to 
be: dorsal foot: 4.8 cm x 3.5 cm x 0.1 cm. Leg: 9.8 cm x 5.8 cm x 0.1 cm. Medial heel: 4.7 cm x 3.6 cm x 0.1 
cm. First and second digit: 1 cm x 0.5 cm x 0.1 cm. The size of the above-mentioned wounds exceeds 25 cm2 
and meets the criteria for code 15275.  
 
Code 15276 is application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, 
hands, feet and or multiple digits, total wound service up to 100 cm2: each additional 25 cm2 wound service 
area.  The aggregate of the wound sizes far exceeds the additional 25 cm2.  Therefore, the medical records do 
support the billing of code 15276 for this enrollee. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 15275 and 15276 have been met. Therefore, we decided that the Plan has 
to pay for the Application of skin substitute graft (15275 and 15276) provided on March 29, 2021.  
 
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.