Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 52001 and 52204. We decided that the Plan does not have to pay for 
52214 and 52240.  
 
You asked the Plan to pay for procedure codes 52001, 52204, 52214, and 52240 rendered on August 21, 2022.. 
You say that this should be paid for. The Plan says that the denied codes remain not supported. 
 
We decided that the Plan has to pay for 52001 and 52204.   
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of the overturned codes are: 
 
CPT 52001: 
 
Cystourethroscopy with irrigation and evacuation of multiple obstructing clots 
 
CPT 52204: 
 
Cystourethroscopy, with biopsy(s) 
 
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 52001 and CPT 52204. Our reviewer says that 
CPT code 52001 is supported. The documentation describes cysto with irrigation and evacuation of clots. 
Additionally, CPT code 52204 is supported. The documentation states that a biopsy was performed with cold 
cup forceps. 
 
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 
52001 and 52204.  
 
We also decided that the Plan does not have to pay for 52214 and 52240. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of the upheld codes are: 
 
CPT 52214: 
 
Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic 
fossa, urethra, or periurethral glands 
 
CPT 52240: 
 
Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; LARGE 
bladder tumor(s) 
 
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 52214 and CPT 52240. Our reviewer says that 
CPT code 52240 is not supported. The documentation does not contain measurements of the bladder tumor. Per 
CPT rules, it cannot be verified that the tumor was large (based on weight/size). Additionally, CPT code 52214 
is not supported. The documentation does not contain evidence that fulguration of trigone, bladder neck, 
prostatic fossa, urethra, or periurethral glands was 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 52214 and 52240 have not been met. Therefore, we decided that the Plan does 
not have to pay for 52214 and 52240. 
 
 
 
 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.