Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 1 unit of procedure code 77280. We decided that the Plan does not 
have to pre-approve the remaining 7 units of procedure code 77280 and 1 unit of procedure code 77290.  
 
You asked the Plan to pre-approve 8 units of procedure code 77280 and 1 unit of procedure code 77290. You 
say that the services are medically necessary. The Plan says that procedure codes 77280 and 77290 are not 
medically necessary. 
 
We decided that the Plan has to pre-approve 1 unit of procedure code 77280.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 to pre-approve 8 units of procedure code 77280. Our 
reviewer says that 1 unit of procedure code 77280 is medically necessary at this time. Our physician reviewer 
found 1 unit of 77280 prior to the first treatment (since initial simulation would be simple in this case) and if 
billed on the 1
st
 day of treatment, this code would supersede the billing for treatment on that day, is medically 
necessary. Otherwise, billing for daily simple simulations would not be furnished in accordance with accepted 
standards of medical practice. Therefore, we decided that the Plan has to pre-approve 1 unit of procedure code 
77280.  
 
We also decided that the Plan does not have to pre-approve the remaining 7 units of procedure code 
77280 and 1 unit of procedure code 77290. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 to pre-approve the remaining 7 units of procedure code 
77280 and 1 unit of procedure code 77290. Our reviewer says that the remaining 7 units of procedure code 
77280 and 1 unit of procedure code 77290 are not medically necessary at this time. Our physician reviewer 
found billing for 77290 is not supported by the case records as an ultrasound to determine depth and size or 
target would more appropriately be billed as a simple vs complex simulation. Additionally, 1 unit of 77280 
prior to the first treatment (since initial simulation would be simple in this case) and if billed on the 1
st
 day of 
treatment, this code would supersede the billing for treatment on that day, is medically necessary. Otherwise, 
billing for daily simple simulations would not be furnished in accordance with accepted standards of medical 
practice. Therefore, we decided that the Plan does not have to pre-approve the remaining 7 units of procedure 
code 77280 and 1 unit of procedure code 77290. 
 
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.