Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services coded as 49905 provided on February 5, 2021.
You asked the Plan to pay for the surgical services. You say that you would like this claim reprocessed based on the medical documentation submitted. The Plan denied your request. The Plan says the procedure as billed is not supported by the medical records submitted.
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 49905 is omental flap, intra-abdominal (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 the surgical services. Our reviewer says that the medical records do not support the code as billed. Our reviewer found that the medical records provided do not include sufficient documentation of necessary criteria to validate 49905 was performed on February 5, 2021. Per the National Correct Coding Initiative Policy Manual regarding CPT 49905 "the physician mobilizes an omental flap for reconstruction of a defect. The surgical recipient site of the flap is prepared. An upper abdominal transverse or midline incision is made. A laparotomy and manual exploration of the abdominal cavity is done first and the omentum and transverse colon are delivered from the cavity. The omentum is dissected from the transverse colon from left to right and small vessels are ligated. When completely separated from the transverse colon, the omentum is dissected from the stomach with careful clamping, division, and ligation of vessels. The omentum is fully mobilized and pedicled on the right or left gastroepiploic vessel, depending on the purpose. More incisions and tunneling may be necessary to bring the flap into its new location to fill a defect. The flap may be used as a pedicled transposition flap or a free microvascular transfer flap. Report 49904 when the flap is transpositioned to repair an extra-abdominal defect, such as chest wounds after radiation and mastectomy or lower extremity trauma wounds. Report 49905 when the omental flap is repositioned to repair a defect intra-abdominally. Report 49906 when the omentum is used as a free vascularized transfer flap to repair defects such as hemifacial atrophy. Microvascular anastomosis is performed to maintain blood flow to the omental flap. The abdominal incision is closed. If a separate split-thickness skin graft is required for omental coverage, it is done immediately and applied directly over the omentum and a dressing is applied. Code 49904 is reported when an extra-abdominal omental flap is used for reconstruction of sternal or chest wall defects; harvest and transfer are included in these services. If a different surgeon harvests the omental flap, the two surgeons should report 49904 as co-surgeons and append modifier 62. Do not report 49905 with 44700. Report 49906 for free omental flap with microvascular anastomosis. Use of an operating microscope is included in 49906. Do not report 69990 separately." This description was not documented in the operative report. 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 surgical services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services coded as 49905 provided on February 5, 2021.