Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has the services 24515, 25360 and 64718. We decided that the Plan does not have the 
services 24101.  
 
You asked the Plan the services surgical services provided to the enrollee on February 2, 2022.. You say that 
this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has the services 24515, 25360 and 64718.  
 
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 24515, CPT 64718, and CPT 25360.  The definition of these codes is: 
 
CPT 24515: 
 
Open treatment of humeral shaft fracture with plate/screws, with or without cerclage 
 
CPT 25360: 
 
Osteotomy; ulna 
 
CPT 64718: 
 
Neuroplasty and/or transposition; ulnar nerve at the elbow 
 
Our reviewer says that the procedure details that she was noted to have lateral and medial condyles available 
for fixation via K-wire and a preliminary reduction was completed with fluoroscopy in the AP and lateral 
planes to ensure anatomic reduction was completed. A positional screw was then drilled and placed to allow for 
removal of K-wires to allow for plate placement. A posterior lateral plate and medial epicondylar plate were 
then placed and positional screws were drilled and placed. Screws were then placed proximally and distally to 
the fracture site to allow for adequate fixation and full range of motion. Therefore, the records do support that 
CPT 24515: open treatment of humeral shaft fracture with plate/screws, with or without cerclage- was rendered 
in this case. 
 
In terms of CPT 25360, the procedure details that a guide pin was then placed into the olecranon longitudinally 
and a screw was then removed to allow for olecranon to be prepped for the osteotomy. A chevron osteotomy 
was then completed, and the olecranon was then elevated. Olecranon osteotomy was extra-articular and triceps 
musculature was then elevated from the posterior surface of the distal humerus and midshaft humerus. 
Therefore, the records do support that CPT 25360: osteotomy, ulna- was rendered in this case. 
 
In terms of CPT 64718, the procedure details that the ulnar nerve was noted and this was dissected and 
transposed anteriorly. Therefore, the records support that CPT 64718: neuroplasty and/or transposition of the 
ulnar nerve at the elbow- was rendered in this case. 
 
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 the services 
24515, 25360 and 64718.  
 
We also decided that the Plan does not have the services 24101. 
 
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 24101. The definition of this code is "Elbow 
arthrotomy, with joint exploration, with or without biopsy, with or without removal of loose or foreign body." 
 
Our reviewer says that the procedure details that she was noted to have approximately 10-20 pieces of the distal 
humerus. All nonviable fragments were then debrided and sent as specimens. However, this was not indicated 
to be in the elbow joint specifically; therefore, CPT 24101 is not supported to have been rendered in this case. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 24101 have not been met. Therefore, we decided that the Plan does not have the 
services 24101. 
 
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.