Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 64447-XU. We decided that the Plan does not have to pay for 01402-
AA (160 units) and 62322-XU .  
 
You asked the Plan to pay for practitioner services provided on May 30, 2023, billed with procedure codes 
01402-AA (160 units), 62322-XU and 64447-XU. You say that the claim is billed correctly and should be paid. 
The Plan says that documentation does not support the billed codes. We decided that the Plan has to pay for 64447-XU.  
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed. 
 
We asked our coding reviewer 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 item/service at issue. Our reviewer says 
that documentation partially supports the billed codes. Our coding reviewer found 160 units of 01402 is not 
supported. The record states anesthesia started at 719 and ended at 957, after which the peripheral nerve block 
was administered, which equals 158 minutes. 62322-XU is not supported as a separately identifiable procedure. 
The record shows that the spinal epidural was integral to the anesthesia and is therefore included in the 
anesthesia. 64447-XU is supported as a distinct and separately identifiable procedure. The record states that the 
peripheral nerve block was administered for post op pain control at the request of the surgeon. According to 
NCCI rules, this can be reported separately.  
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for 64447-XU.  
 
We also decided that the Plan does not have to pay for 01402-AA (160 units) and 62322-XU . 
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed. 
 
We asked our coding reviewer 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 item/service at issue. Our reviewer says 
that documentation partially supports the billed codes. Our coding reviewer found 160 units of 01402 is not 
supported. The record states anesthesia started at 719 and ended at 957, after which the peripheral nerve block 
was administered, which equals 158 minutes. 62322-XU is not supported as a separately identifiable procedure. 
The record shows that the spinal epidural was integral to the anesthesia and is therefore included in the 
anesthesia. 64447-XU is supported as a distinct and separately identifiable procedure. The record states that the 
peripheral nerve block was administered for post op pain control at the request of the surgeon. According to 
National Correct Coding Initiative (NCCI) rules, this can be reported separately.  
 
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 item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for 01402-AA (160 units) and 62322-XU . 
 
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.