Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 50605. We decided that the Plan does not have to pay for S2900 and 
52352.  
 
You asked the Plan to pay for surgical services (procedure codes 50605, 52352, S2900) provided to the 
enrollee on June 17, 2022. You say that this should be paid for. The Plan says that the records do not support 
the services billed. 
 
 We decided that the Plan has to pay for 50605.  
 
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 CPT 50605 is "Ureterotomy for insertion of indwelling stent, 
all types." 
 
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 50605 Our reviewer says that the records do 
support that this code was rendered in this case. The enrollee underwent laparoscopic (with robot) 
dismembered pyeloplasty, ureterotomy with stent placement, pyelolithotomy, and ureteroscopic stone 
extraction on 6/17/22. 
  
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 
50605.  
 
We also decided that the Plan does not have to pay for S2900 and 52352. 
 
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 denied codes is: 
 
CPT 52352: 
 
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral 
catheterization is included) 
 
Healthcare Common Procedure Coding System (HCPCS) S9200: 
 
Surgical techniques requiring use of robotic surgical system (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 for these codes. Our reviewer says that the records do 
not support CPT 52352 which is when the provider performs a cystourethroscopy, the inspection of the interior 
of the bladder, the urethra, prostatic urethra, and ureteric openings using a cystoscope passed through the 
urethra and into the bladder and performs a ureteroscopy (inspection of the ureters) and/or a pyeloscopy 
(inspection of the renal pelvis). The provider finds a calculus (stone) and removes or manipulates its position so 
that it can pass on its own or reduce obstruction. There is not a specific CPT code for laparoscopic 
pyelolithotomy (as was done here) so the best code to use would be 53899 unlisted procedure, urinary system. 
 
Additionally, we find that procedure code S2900 has a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure code S2900 is not valid for Medicare purposes. Based on this information, we 
decided that Medicare rules for coverage of S2900 have not been met.  
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of S2900 and 52352 have not been met. Therefore, we decided that the Plan does 
not have to pay for S2900 and 52352. 
 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.