Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neuroplasty and/or transposition; cranial nerve (CPT
64716).
You asked the Plan to pre-approve Neuroplasty and/or transposition; cranial nerve (CPT 64716). You say that
this treatment was medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare
coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated
that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Neuroplasty
and/or transposition; cranial nerve (CPT 64716). The Maximus Physician Reviewer determined that the
medical records support the billing of code 64716 provided on May 19, 2021. The reviewer found the enrollee
had osteoporosis, thyroid nodules and normocalcemic hyperparathyroidism. She had removal of the superior
right and left parathyroid glands, with dissection of the recurrent laryngeal nerves as part of the procedure. The
operative note described the dissection of the recurrent laryngeal nerves and given the surgery this is a
reasonable approach.
The Plan requested a reopen and notes that procedure code 64716 x2 (neuroplasty and/or transposition of a
cranial nerve) is documented in the operative note submitted for review.
The Plan states that this procedure is considered inclusive to CPT code 60240, a total or complete
thyroidectomy; therefore, the code cannot be verified. The Plan states the records document "Surgical approach
including identification of anatomical landmarks, incision, evaluation of the surgical field, debridement of
traumatized tissue, lysis of adhesions, and isolation of structures limiting access to the surgical field such as
bone, blood vessels, nerve, and muscles including stimulation for identification or monitoring are considered
component services integral to a comprehensive service and therefore, not separately reportable. As a result,
the requested procedure code would be considered inclusive to procedure code 60240. Therefore, the requested
code 64716 x2 cannot be verified."
The medical records show the enrollee is a 70-year-old woman with a multinodular goiter, suspected
hyperparathyroidism, and a possible hot nodule. A total thyroidectomy was recommended, as a partial
lobectomy would compromise the bilateral recurrent laryngeal nerves because of how large the isthmus nodule
was. The operative note dated May 19, 2021, lists preoperative diagnoses of thyroid carcinoma, eucalcemic
hyperparathyroidism, and osteoporosis. Total thyroidectomy and microdissection of the bilateral recurrent
laryngeal nerves were performed, as well as removal of two parathyroid glands. The operation included
identification and meticulous dissection of the recurrent laryngeal nerve. The general guidance for this code is
that it is used for release and/or relocation of cranial nerve.
Our Medical Director has concluded that the Plan is correct in this case. A sufficient portion of the recurrent
laryngeal nerve should be dissected during thyroidectomy to ensure its safety during dissection and removal of
the thyroid gland. This procedure would be considered to be a component service integral to the comprehensive
surgery and would not be separately reportable. Therefore, Medicare billing criteria were not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Neuroplasty and/or transposition; cranial nerve (CPT 64716) have not been met.
Therefore, we decided that the Plan does not have to pre-approve Neuroplasty and/or transposition; cranial
nerve (CPT 64716).