Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 10121, 49905, 10035, 10036, and 38770-59 billed for 
date of service June 1, 2022. 
 
You asked the Plan to pay for codes 10121, 49905, 10035, 10036, and 38770-59. You say that these services 
should be paid. The Plan denied your request. The Plan says the medical records do not support the billing of 
codes 10121, 49905, 10035, and 10036, or the use of modifier 59 with code 38770. 
 
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 codes 10121, 49905, 10035, 10036, and 38770-59 are as 
follows: 
 
10121-Incision and removal of foreign body, subcutaneous tissues; complicated. 
 
49905-Omental flap, intra-abdominal (List separately in addition to code for primary procedure). 
 
10035-Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), 
percutaneous, including imaging guidance; first lesion. 
 
10036-Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), 
percutaneous, including imaging guidance; each additional lesion (List separately in addition to code for 
primary procedure). 
 
38770-Pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate 
procedure). 
 
49205-Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, 
mesenteric, or retroperitoneal primary or secondary tumors; largest tumor greater than 10.0 cm diameter. 
 
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 10121, 49905, 10035, 10036, and 38770-59. Our 
reviewer says that codes 10121, 49905, 10035, 10036, and 38770-59 are not supported in the medical record. 
Our reviewer found for code 10121, the operative report does not include documentation of foreign body in 
subcutaneous tissue.  Was unable to cite report as a procedure performed in subcutaneous tissue layer was not 
documented. The hypodermis (subcutaneous tissue) is the innermost layer of skin in your body.  Therefore, this 
procedure denied correctly. For code 49905, the operative report does not include enough information to 
confirm an intra-abdominal omental flap was performed per NCCI Policy criteria " The omentum is dissected 
from the transverse colon from left to right and small vessels are ligated.  When completely separated from the 
transverse colon from left to right and small vessels are ligated.  When completely separated from the 
transverse colon, the omentum is dissected from the stomach with careful clamping, division and ligation of 
vessels.  The omentum is full mobilized and pedicled on the right or left gastroepiploic vessel, depending on 
the purpose".  to include documentation of anatomic reconstructive indication, tecnical criteria, and all 
components of the creation of an omental flap.  Operative report documents "We actually mobilized of portion 
of the omentum to wrap it down to cover the surrounding area in the pelvis where the previous dissection had 
occurred adjacent to where mesh was encountered in the inguinal ligament, so the utilization of that 
intraabdominal omental flap was important to be able to cover this area to prevent any bowel or any other 
contents hitting this area potentially fistualizing in the future".  Operative report does not support criteria for 
service billed. For codes 10035 and 10036, the operative report does not include documentation of placement of soft tissue localization device prior to biopsy. This procedure was not documented. For code 38770-59,  the 
operative report includes documentation of a excision of intra-abdominal tumor, and pelvic 
lymphadenectomy.  In this case, the intra-abdominal tumor excision is the more comprehensive procedure. 
Therefore, pelvic lymphadenectomy would be included in the more comprehensive procedure performed. 
 
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 10121, 49905, 10035, 10036, and 38770-59 have not been met. 
Therefore, we decided that the Plan does not have to pay for codes 10121, 49905, 10035, 10036, and 38770-59 
billed for date of service June 1, 2022.