Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services. We decided that the Plan does not have to pay for CPT 
49020.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that the records 
do not support these services billed. 
 
We decided that the Plan has to pay for CPT 49905.  
 
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 49905 is "Omental flap, intra-abdominal (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 CPT 49905. Our reviewer says that this service is 
supported in the medical record. Our physician reviewer found that the operative report documents that "the 
omentum was taken off the transverse colon from the mid portion all the way up to the splenic flexure, which 
was quite redundant. Small bowel was swept out from underneath the colon, put in its proper position, the 
omental flap brought sown along the left side. The omental flap was created by basing the intact blood supply 
off of the Left-most vessels (splenic flexure base as noted). It was rotated into place to fill the abscess cavity 
without interrupting the blood supply to fill that defect." Per the coding guidelines, CPT 49905 is reported 
when an omental pedicle flap is created and positioned to fill or correct an intra-abdominal defect, such as an 
enterocele or dead space, resulting from a colovaginal or colovesical repair. The operative report describes 
this 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 the services have been met. Therefore, we decided that the Plan has to pay for 
CPT 49905.  
 
We also decided that the Plan does not have to pay for CPT 49020. 
 
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 49020 is "Drainage of peritoneal abscess or localized 
peritonitis, exclusive of appendiceal abscess, open." 
 
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 49020. Our reviewer says that these services 
were not supported by the medical records. Our physician reviewer found that the operative report describes 
that during the primary procedure an abscess was treated. The procedure would be inclusive to the primary 
procedure unless increased procedural services are documented, then the appropriate modifier would be 
appended to 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 CPT 49020 have not been met. Therefore, we decided that the Plan does not 
have to pay for CPT 49020. 
 
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.