Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for CPT 37617. We decided that the Plan does not have to pay for CPT 
44005 or CPT 97606.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that the provider 
did not bill as required by Medicare coding regulations. 
 
We decided that the Plan has to pay for CPT 37617.  
 
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 
code 37617 is "Ligation, major artery (eg, post-traumatic, rupture); abdomen." 
 
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 37617. Our reviewer says that the enrollee 
presented in septic shock, and was found to have a perforated cecum with gross spillage, necessitating 
colectomy and lysis of adhesions. There was findings of bleeding from the superior pancreaticoduodenal artery 
which required ligation. The etiology of the bleeding cause was not able to be determined. Ligation of the 
major bleeding vessel is supported by the operative report in the file. 
 
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 to pay for 
37617.  
 
We also decided that the Plan does not have to pay for CPT 44005 and 97606. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for Current Procedural 
Terminology (CPT) code 97606 - "Negative pressure wound therapy (eg, vacuum assisted drainage collection), 
utilizing durable medical equipment (DME), including topical application(s), wound assessment, and 
instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters." 
The Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure. 
 
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 an assistant at surgery. Our reviewer says that 
while the procedure overall required an assistant surgery, CPT 97606 does not require the assistant. Our 
physician reviewer found that application of a wound vac at the end of the surgery would not specifically 
require an assistant surgeon. 
 
Additionally, in terms of CPT 44005, 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, we 
have confirmed that code 44005 (Enterolysis (freeing of intestinal adhesion) (separate procedure)) is a column 
II code to column I code 44144 with a modifier indicator of 0. The column II code is therefore not payable. 
Based on the claim submitted, Medicare billing criteria have not been 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 44005 and 97606 have not been met. Therefore, we decided that the Plan does 
not have to pay for CPT 44005 and 97606. 
 
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.