Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 64415-XE-RT. We decided that the Plan does not have to pay for 
01638-QK (138 units).   
You asked the Plan to pay for practitioner services provided on August 18, 2022, billed with procedure codes 
01638-QK (138 units) and 64415-XE-RT. 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 64415-XE-RT.  
 
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 64415-XE-RT is supported 
by the medical record. The record states that the block was administered for postoperative pain control at the 
request of the surgeon, which meets criteria to report it as a separately identifiable procedure. 01638-QK (138 
units) is not supported. The record states that anesthesia was administered from 702-920, which equals 138 
minutes. The plan states that the time spent administering the postoperative pain control block is not included 
in that time. Since the procedure note states that the block was performed 659-703, that would equal 137 
minutes of billable anesthesia time per the payer's stated policy.   
 
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 64415-XE-RT.  
 
We also decided that the Plan does not have to pay for 01638-QK (138 units). 
 
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 64415-XE -RT is supported 
by the medical record. The record states that the block was administered for postoperative pain control at the 
request of the surgeon, which meets criteria to report it as a separately identifiable procedure. 01638-QK (138 
units) is not supported. The record states that anesthesia was administered from 702-920, which equals 138 
minutes. The plan states that the time spent administering the postoperative pain control block is not included 
in that time. Since the procedure note states that the block was performed 659-703, that would equal 137 
minutes of billable anesthesia time per the payer's stated policy.   
 
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 01638-QK (138 units). 
 
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.