Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for debridement of muscle and/or fascia (11043, 11046). We decided that
the Plan does not have to pay for debridement of bone (11044).
You asked the Plan to pay for debridement of muscle and/or fascia and debridement of bone. You say that the
services at issue were provided on an emergency basis. The Plan says that records do not support the services
billed.
We decided that the Plan has to pay for debridement of muscle and/or fascia.
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 11043 is "Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if
performed); first 20 sq cm or less." The definition of code 11046 is "Debridement, muscle and/or fascia
(includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof
(List separately in addition to code for primary procedure)."
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 debridement of muscle and/or fascia. Our reviewer says that
debridement of muscle and/or fascia meets criteria for payment. Our reviewer found that documentation does
support CPT 11043 and CPT 11046, for the left buttock, and therefore should be covered.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of debridement of muscle and/or fascia have been met. Therefore, we decided that
the Plan has to pay for debridement of muscle and/or fascia (11043, 11046).
We also decided that the Plan does not have to pay for debridement of bone.
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 11044 is "Debridement, bone (includes epidermis,
dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less."
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 debridement of bone. Our reviewer says that debridement of
bone does not meet criteria for payment. Our reviewer found that the provided procedure report documents
debridement taken down to bone but does not support debridement of bone.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of debridement of bone have not been met. Therefore, we decided that the Plan
does not have to pay for debridement of bone (11044).
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.