Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 92886, 92025, 92020, 76514, and 92134. We decided that the Plan does 
not have to pay for 91236 and 92250.  
 
You asked the Plan to pay for various ophthalmology services provided to the enrollee on May 17, 2022.. You 
say that this should be paid for. The Plan says that the denied codes remain not supported. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 CPT 76514: 
 
Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal 
thickness) 
 
CPT 92020: 
 
Gonioscopy (separate procedure) 
 
CPT 92025: 
 
Computerized corneal topography, unilateral or bilateral, with interpretation and report 
 
CPT 92134: 
 
Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, 
unilateral or bilateral; retina 
 
CPT 92136: 
 
Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation 
 
CPT 92250: 
 
Fundus photography with interpretation and report 
 
CPT 92286: 
 
Anterior segment imaging with interpretation and report; with specular microscopy and endothelial cell 
analysis  
 
We decided that the Plan has to pay for 92886, 92025, 92020, 76514, and 92134.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 for 92886, 92025, 92020, 76514, and 92134. Our 
reviewer says that the documentation and interpretation support all of these codes being rendered.  
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
92886, 92025, 92020, 76514, and 92134. 
 
We also decided that the Plan does not have to pay for 91236 and 92250. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 for CPT 92136 and CPT 92250. Our reviewer says that 
for procedure code 92136, global and technical (TC) components are classified as bilateral procedures where the bilateral adjustment does not apply, the Physician Fee Schedule amount for a global procedure represents 
payment for the technical components (TC) for both eyes and one professional component (26). The technical 
component procedures (TC) represent payment for both eyes. These procedures should be reported on a single 
claim line without the 50 or RT/LT modifiers and if applicable one additional line for the opposite professional 
component (26). In terms of CPT 92250, this code is included in the payment for CPT 92134; therefore, it 
cannot be separately reimbursed. The documentation does not support that the procedure was distinct or 
independent from other services performed. Therefore, the use of modifier 59 is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 91236 and 92250 have not been met. Therefore, we decided that the Plan does 
not have to pay for 91236 and 92250. 
 
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.