Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 27520-54-RT. We decided that the Plan does not have 
to pay for evaluation and management (EM) code 99285-57.  
 You asked the Plan to pay for practitioner services provided on March 3, 2023, billed with evaluation and 
management (EM) code 99285-57 and procedure code 27520-54-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 procedure code 27520-54-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 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 pay for the practitioner services provided. Our 
reviewer says that documentation partially supports the billed codes Our physician reviewer found that there 
was treatment for a right knee fracture, so CPT 27520-RT is supported. However, while documentation 
supports a comprehensive exam, it does not support a comprehensive history or medical decision making of 
high complexity, so 99285 is not supported.  
 
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 practitioner services provided have been met. Therefore, we decided that the 
Plan has to pay for procedure code 27520-54-RT.  
 
We also decided that the Plan does not have to pay for evaluation and management (EM) code 99285-57. 
 
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 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 pay for evaluation and management (EM) code 
99285-57. Our reviewer says that documentation partially supports the billed codes Our physician reviewer 
found that there was treatment for a right knee fracture, so CPT 27520-RT is supported. However, while 
documentation supports a comprehensive exam, it does not support a comprehensive history or medical 
decision making of high complexity, so 99285 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of evaluation and management (EM) code 99285-57 have not been met. Therefore, 
we decided that the Plan does not have to pay for evaluation and management (EM) code 99285-57. 
 
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.