Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for a muscle, myocutaneous, or fasciocutaneous flap procedure. We 
decided that the Plan does not have to pay for adjacent tissue transfers or rearrangements.  
 
You asked the Plan to pay for a muscle, myocutaneous, or fasciocutaneous flap procedure and for adjacent 
tissue transfers or rearrangements. You say that you have provided records to support the services billed. The Plan says that rules for payment have not been met because the available records do not support the codes 
billed. 
 
We decided that the Plan has to pay for a muscle, myocutaneous, or fasciocutaneous flap procedure.  
 
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 15734 is "Muscle, myocutaneous, or fasciocutaneous flap; trunk." 
 
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 a muscle, myocutaneous, or fasciocutaneous 
flap procedure. Our reviewer says that criteria for payment for CPT code 15734 have been met. Our physician 
reviewer found that the available documentation does support the use of 15734 was performed on both left and 
right and should be coded as such with two units. The procedure report accurately describes the muscle flap 
process for both left and right side.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a muscle, myocutaneous, or fasciocutaneous flap procedure have been met. 
Therefore, we decided that the Plan has to pay for a muscle, myocutaneous, or fasciocutaneous flap procedure.  
 
We also decided that the Plan does not have to pay for adjacent tissue transfers or rearrangements. 
 
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 14301 is "Adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm"; and of code 14302 is "Adjacent tissue transfer or rearrangement, any 
area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary 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 to pay for adjacent tissue transfers or rearrangements. 
Our reviewer says that criteria for payment for CPT codes 14301 and 14302 have not been met. Our physician 
reviewer found that the available documentation does not accurately demonstrate these were separate 
procedures from the hernia repair and rives stoppa repair. The provider made a comment that the hernia repair 
was closed but upon the attempted closure the provider felt there was tension and added additional to this 
procedure making the repair complex. The other complex repair the provider was describing was from the 
wound created by the excision and laparotomy, but these repairs are included in the primary procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of adjacent tissue transfers or rearrangements have not been met. Therefore, we 
decided that the Plan does not have to pay for adjacent tissue transfers or rearrangements. 
 
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.