Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (43281 and 43502) provided on 
September 6, 2022. 
 
You asked the Plan to pay for the surgical services. You say that the services are supported as billed. The Plan 
denied your request. The Plan says the services are not supported by the records. 
 
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 43281 is laparoscopy surgical, repair of paraesophageal 
hernia, includes fundoplasty, when performed, without implantation of mesh. The definition of code 43502 is 
gastrotomy; with suture repair of pre-existing esophagogastric laceration (eg, Mallor-Weiss). 
 
We asked our coder 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 the surgical services. Our reviewer found the documentation 
submitted was reviewed and does not meet criteria. The operative report does not describe a laparoscopy repair 
of paraesophageal hernia without mesh and therefore cannot be verified. Per National Correct Coding Initiative 
(NCCI) Policy, "The physician repairs a paraesophageal hernia using a laparoscope and may also perform a 
fundoplasty when indicated. With the patient under anesthesia and in a supine position, the physician places 
laparoscopic ports in the upper abdomen, through which the appropriate surgical instruments are inserted. With 
the left lateral segment of the liver retracted, the hiatus is exposed. The physician reduces the herniated 
stomach into the abdomen and dissects the hernia sac and gastroesophageal fat pad using a combination of 
sharp and blunt dissection. If a fundoplasty is indicated, the physician identifies the fundus and the esophagus 
and resects them. The fundus is wrapped around the lower end of the esophagus, which is rejoined to the 
stomach with sutures. Operative report documents: The diaphragmatic repair seemed to be intact and although 
this repair was tight and intact, the entire upper half of the stomach was sucked back into the chest, similar to 
the way it was preoperatively...Despite this tight repair upper half of the stomach had sucked back up into the 
chest and did create a very tight cicatrix or hourglass formation of the stomach, which is probably where the 
radiologist felt like some of the blood supply was being compromised on the gastric wall. does not describe this 
procedure". In this case, this procedure cannot be verified due to insufficient documentation. 
 
For code 43502, the documentation submitted was reviewed and does not meet criteria. The operative report 
does not include documentation of, Gastrotomy; with suture repair of pre-existing esophagogastric laceration 
per NCCI Policy, "The physician performs a gastrostomy and explores gastric area, removes a foreign body or 
corrects a mucosal defect. The physician makes a midline epigastric incision and retracts the skin and 
underlying tissues laterally. The stomach is incised and explored. In 43500, a foreign body is removed. In 
43502, an esophagogastric laceration is identified and bleeding is controlled with electrocautery or ligation of 
vessels, and the mucosa is drawn over the defect and sutured". Our coder was unable to cite report, as 
gastrotomy; with suture repair was not found in operative report, and therefore, cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical services (43281 and 43502) provided on September 6, 2022.