Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 15004 and 97605. We decided that the Plan does not 
have to pay for procedure codes 11960, 20702, 20700, 15275, and 15276. 
 
You asked the Plan to pay for procedure codes 11960, 15004, 20702, 20700, 15275, 15276, and 97605 billed 
for April 7, 2023. You say that you disagree with the denial. The Plan says that the services are not covered. 
 
We decided that the Plan has to pay for procedure codes 15004 and 97605. 
 
The rules say that modifier AS is billed to indicate that a PA, NP or CNS served as the assistant at surgery. 
Modifier 80, 81 or 82 must also be billed when modifier AS is billed. The Plan must follow Medicare rules. 
The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the 
IRE information regarding its decision to deny coverage or payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that codes 15004 and 97605 cannot be paid with the billed 
modifiers. The file shows that codes 15004 and 97605 were billed with the -AS and -82 modifiers. Medicare 
rules state that modifier -82 must be billed when modifier -AS is billed, or the claim is rejected. The Plan has 
not provided any documentation to support that the modifiers billed for codes 15004 and 97605 cannot be paid 
per Medicare rules. Therefore, we decided that the Plan has to pay for procedure codes 15004 and 97605 billed 
for April 7, 2023. 
 
We also decided that the Plan does not have to pay for procedure codes 11960, 20702, 20700, 15275, and 
15276. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 11960, 15275, and 15276. The Medicare Fee Schedule Database contains 
a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant 
surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare 
coverage criteria for these services have not been met. 
 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 20702 is manual preparation and insertion of drug-
delivery device(s), intramedullary (List separately in addition to code for primary procedure). The definition of 
code 20700 is manual preparation and insertion of drug-delivery device(s), deep (eg, subfascial) (List 
separately in addition to code for primary procedure). 
 
We find that CPT codes 20702 and 20700 are not supported in the medical record. Specifically, these are add-
on codes that were not billed with a required primary procedure code. Based on this information, we decided 
that Medicare rules for coverage of these services have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 11960, 20702, 20700, 15275, and 
15276 billed for April 7, 2023. 
 
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.