Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 19120-XU, 13101-XS and 
11406-XS provided on November 17, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says these services have not been billed with 
the appropriate CPT codes based on the medical records submitted. 
 
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 definitions are as followed: 
 
CPT 19120 -  Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct 
lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions  
 
CPT 13101 -  Repair, complex, trunk; 2.6 cm to 7.5 cm   
CPT 11406 - Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms 
or legs; excised diameter over 4.0 cm 
 
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 medical services. Our reviewer says that the 
documentation does not support payment for the CPT codes as billed. Our reviewer found the following: 
 
CPT 19120 - The operative report does not include documentation of an excision of cyst, fibroademoma or 
other tumor. This procedure was not found in the operative report. Therefore, the billed service cannot be 
verified. 
 
CPT 13101  The operative report does not support criteria per CPT code description for complex repair. Per 
CPT guidelines:  Complex repair includes the repair of wounds that, in addition to the requirements for 
intermedicate repair, require at least one of the following: exposure of bone, cartilage, tendon, or named 
neurovascular structure; debridement of wound edges (eg, traumatic lacerations or 
avulsions); extensive undermining (defined as a distance greater than or equal to the maximum width of the 
defect, measured perpendicular to the closure line along at least one entire edge of the defect); involvement of 
free margins of helical rim, vermilion border, or nostril rim; placement of retention sutures. The 
documentation shows layered closure of both wounds to support the code for intermediate wound repair, but 
there is no documentation showing exposure of bone, cartilage, tendon, debridement of wound edges, or 
extensive undermining. Therefore, this procedure, cannot be verified. 
 
CPT 11406  The operative report describes excision of fat necrosis. CPT 11406 is the incorrect code to report 
for this procedure and cannot be approved for coverage. 
 
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 medical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services coded 19120-XU, 13101-XS and 11406-XS provided on 
November 17, 2021.