Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 27645. We decided that the Plan does not have to pay 
for 15271, 15275, 15276, 15002, 15004, 20700, and 97606.  
 
You asked the Plan to pay for procedure codes 15271, 15275, 15276, 27645, 15002, 15004, 20700, and 97606 
provided on March 31, 2022. You say that you would like the Plan to reconsider their denial of payment. The 
Plan says that the services are not covered. 
 
We decided that the Plan has to pay for procedure code 27645.  
 
The Plan must follow Medicare rules. Medicare rules say that for procedures with an assistant surgery indicator 
of 2, the payment restriction for assistants at surgery does not apply and the assistant surgeon services will be 
paid.  
 
In this case, you billed assistant surgery services for CPT code 27645. The Medicare Fee Schedule Database 
contains a surgical indicator of 2 for this procedure. Based on this information, we decided that Medicare rules 
for coverage of 27645 have been met. Therefore, we decided that the Plan has to pay for procedure code 27645.  
 
We also decided that the Plan does not have to pay for 15271, 15275, 15276, 15002, 15004, 20700, 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) codes 15002, 15004, 20700, and 97606. The Medicare Fee Schedule Database contains a 
surgical indicator of 0 for these codes. 
 
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 to pay for 15002, 15004, 20700, and 97606. Our 
reviewer says that the medical records do not support that the assistant at surgery services provided for 
procedure codes 15002, 15004, 20700, and 97606 were medically necessary.  Our physician reviewer found the record indicates that the enrollee underwent the noted procedures. The 
operative note provided does not establish the medical necessity of the assistant at surgery services for which 
claims were submitted. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The 
requested service is not recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 15002, 15004, 20700, and 97606 have not been met. 
 
Medicare rules also state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are 
not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) codes 
15271, 15275, and 15276. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these 
codes. This means that Medicare has determined that an assistant surgeon is not medically necessary and will 
not be paid. Based upon this information, we find that Medicare coverage criteria for codes 15271, 15275, and 
15276 have not been met.  
 
Therefore, we decided that the Plan does not have to pay for 15271, 15275, 15276, 15002, 15004, 20700, 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.