Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for CPT 15721. We decided that the Plan does not have to pay for the rest 
of the codes.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that this was not 
coded correctly. 
 
We decided that the Plan has to pay for 15721.  
 
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 15271 is "Application of skin substitute graft to trunk, 
arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area."  
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 15271. Our reviewer says that that the medical 
records support the use of procedure code 15271, due to the provider placing amnion allograft. 
 
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 
15721.  
 
We also decided that the Plan does not have to pay for the rest of the codes. 
 
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 rest of the denied codes is: 
 
CPT 80048: 
 
Basic metabolic panel (Calcium, total) This panel must include the following: Calcium, total (82310) Carbon 
dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) 
Sodium (84295) Urea nitrogen (BUN) (84520) 
 
CPT 85025: 
 
Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential 
WBC count 
 
CPT 93005: 
 
Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report 
 
HCPCS C1762: 
 
Connective tissue, human (includes fascia lata) 
 
HCPCS J0690: 
 
Injection, cefazolin sodium, 500 mg 
 
HCPCS J2370: 
 
Injection, phenylephrine hcl, up to 1 ml 
 
HCPCS J2704: 
 
Injection, propofol, 10 mg 
 
HCPCS J3010: 
 
Injection, fentanyl citrate, 0.1 mg 
 
HCPCS J3490:  
Unclassified drugs 
 
 
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 the other codes. Our reviewer says that all other 
procedures were improperly billed, and no medical documentation was provided to support such billing.   
 
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 rest of the codes have not been met. Therefore, we decided that the Plan 
does not have to pay for the rest of the codes. 
 
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.