Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 20610-RT-59. We decided that the Plan does not have to pay for 
99203-25, 77022-RT-XU, and 73562-50.  
 
You asked the Plan to pay for practitioner services provided on May 31, 2022, billed with procedure codes 
99203-25, 77022-RT-XU, 20610-RT-59, and 73562-50. 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 20610-RT-59.  
 
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 that code 20610 is supported 
by the medical record. Based on the documentation, a knee injection with fluoroscopic guidance was 
performed, not an arthrogram. According to CPT rules, this is reported with 20610 and 77002. Code 27369 is 
not correct for this procedure; the record does not support that 27369 was performed. Code 73562 is not 
supported. The record states that 2 views were obtained. There is a more appropriate code for this procedure.  
 
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 20610-RT-59.  
 
 We also decided that the Plan does not have to pay for 99203-25, 77022-RT-XU, and 73562-50. 
 
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. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot 
be paid when the MAI value is 2. The rules also say that submitted claims in which the unit of service exceeds 
the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess units. 
 
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 that code 20610 is supported 
by the medical record. Based on the documentation, a knee injection with fluoroscopic guidance was 
performed, not an arthrogram. According to CPT rules, this is reported with 20610 and 77002. Code 27369 is 
not correct for this procedure; the record does not support that 27369 was performed. Code 73562 is not 
supported. The record states that 2 views were obtained. There is a more appropriate code for this procedure.  
 
We looked at this coder's review, the file, and Medicare rules. In this case, the MUE for CPT code 99203 is 1. 
The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. The MUE for CPT code 
77002 is 1. The MAI value for this code is 3. You billed 2 units of this code, exceeding the MUE. 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 99203-25, 77022-RT-XU, and 73562-50. 
 
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.