Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure codes 20692, 24343, 24345, 
64718) provided to the enrollee on April 14, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
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 the denied codes is: 
 
CPT 20692: 
 
Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation system (eg, 
Ilizarov, Monticelli type) 
 
CPT 24343: 
 Repair lateral collateral ligament, elbow, with local tissue 
 
CPT 24345: 
 
Repair medial collateral ligament, elbow, with local tissue 
 
CPT 64718: 
 
Neuroplasty and/or transposition; ulnar nerve at elbow 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the surgical procedure notes #2 
FiberWires were placed as well as internal stabilizer with guide pins utilized on this internal fixation procedure. 
The procedure notes do not include that any external fixation system utilized. Therefore, the records do not 
support that CPT 20692- application of a multiplane (pins or wires in more than 1 plane), unilateral external 
fixation system (e.g., Ilizarov, Monticelli type) was rendered in this case. Additionally, during the procedure, a 
full-thickness lateral collateral ligament tear of the lateral epicondyle was identified. The lateral collateral 
ligament complex was then sutured with #2FiberSWire suture and a suture anchor was placed just proximal to 
the IJS guide pin as well to repair the common extensors. The lateral collateral ligament complex was then 
repaired as well as the common extensor origin. The annular ligament was repaired with a braided suture prior 
to the collateral ligament repair. Attention was then brought to the medial elbow. The main medial epicondylar 
fragment was reduced, held in place with a K-wire, checked and noted to be satisfactory and reduced. These 
procedures were part of the open treatment of acute or chronic elbow dislocation. Therefore, the records do not 
support that CPT 24343- repair lateral collateral ligament, elbow, with local tissue and CPT 24345- repair of 
medial collateral ligament, elbow, with local tissue were independent and distinct procedures from CPT 24615- 
open treatment of acute or chronic elbow dislocation. In terms of CPT 64718, the procedure notes a posterior 
incision was made over the elbow with crossing radially over the tip of the olecranon. Full-thickness flaps were 
made. The ulnar nerve was identified to the proximal area and then was dissected distally. Osborne ligament 
and cubital tunnel were then identified and was noted to have entrapment of the nerve at this area secondary to 
the fracture. The nerve was then dissected down through the cubital tunnel. The nerve was then dissected down 
through the cubital tunnel. The nerve was then mobilized anteriorly and protected. With the nerve protected, 
the medial epicondylar fracture was able to be identified. This would not be a separate procedure, as this was 
performed to proceed with the open treatment of the radial head. This does not appear to have been 
documented as nor represents a formal anterior nerve transposition. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure codes 20692, 24343, 24345, 64718) provided to the enrollee on 
April 14, 2022.