Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services (procedure codes 33880, 34713, 75956) provided to the enrollee on December 11, 2020.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain not supported.  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 the denied codes is:  CPT 34713:  Percutaneous access and closure of femoral artery for delivery of endograft through a large sheath (12 French or larger), including ultrasound guidance, when performed, unilateral (List separately in addition to code for primary procedure)   CPT 33880:  Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin  CPT 75956:  Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin, radiological supervision and interpretation  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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the procedure report documents two physicians performing, however, documentation is not clear on what procedures each physician performed, as there is only one operative report, and no documentation to support what procedure each provider performed. Each physician should report their distinct operative work in a separate operative report. Claims from both co-surgeons should report the same procedure code with modifier 62 appended. In terms of CPT 34713, per CPT code description "Percutaneous access and closure of femoral artery for delivery of endograft through a large sheath (12 French or larger)." To cite operative report "Pro-guide closure devices were then placed on the left in anticipation of percutaneous closure. From the right femoral approach a 5 French marker Flush catheter was introduced and advanced into the proximal aspect of the ascending aorta." The documentation does not support 12 French or larger, per the code description. In terms of CPT 33880, the procedure report does not describe a proximal graft component deployed and covers the origin of the left subclavian artery. Therefore, this procedure cannot be confirmed. In terms of CPT 75756, the procedure report does not support endovascular repair of descending thoracic aorta in involving coverage of left subclavian artery origin and therefore, this procedure cannot be confirmed.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (procedure codes 33880, 34713, 75956) provided to the enrollee on  December 11, 2020.