Appeal type: ER
Decision: Partially Favorable

 
We decided that the Plan has to pay for 12001, 12013, and 99285. We decided that the Plan does not have to 
pay for 93010.  
 
You asked the Plan to pay for procedure codes 12001, 12013, 93010, and 99285 rendered on April 7, 2023.. 
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 12001, 12013, and 99285.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 12001, 12013, and 99285. Our reviewer says that in 
terms of CPT 99285, the enrollee presented to the emergency room for a fall at a nursing facility. While in the 
emergency department, the physician examined the enrollee for injuries including radiology services for the 
head, cervical spine, facial bones, and chest. A right humeral fracture was noted and treated, as well as 
lacerations. The provider did a thorough work-up on the enrollee, diagnosed the enrollee with lacerations and 
fractures. The enrollee was also found to have a urinary tract infection. Therefore, CPT 99285 is supported. 
 
In terms of CPT 12001 and 12013, the procedure report describes 2cm simple of right hand and right eyebrow. 
Therefore, these procedures are supported in the records. 
 
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 
12001, 12013, and 99285.  
 
We also decided that the Plan does not have to pay for 93010. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 93010. Our reviewer says that the records 
support that the provider performed an interpretation and report for an ECG while the enrollee was in the 
emergency department. However, the records do not support a separate and distinct procedure, as the procedure 
was integral to the fracture treatment and simple repair services performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 93010 have not been met. Therefore, we decided that the Plan does not have to 
pay for 93010. 
 
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.