Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for 31525. We decided that the Plan does not have to pay for 31231 and 
99304.  
 
You asked the Plan to pay for procedure codes 31231, 31525, and 99304 rendered on May 11, 2023. You say 
that this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 31525.  
 
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 CPT 31525 is "Laryngoscopy 
direct, with or without tracheoscopy; diagnostic, except newborn." 
 
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 31525. Our reviewer says that the procedure 
report describes endoscopy, right vocal chord; left vocal chord; epiglottis. The medical record includes 
documentation of procedure and results to support procedure billed. Therefore, this code is verified and 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for 31525.  
 
We also decided that the Plan does not have to pay for 31231 and 99304. 
 
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 remaining codes is: 
 
CPT 31231: 
 
Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) 
 
CPT 99304: 
 
Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a 
medically appropriate history and/or examination and straightforward or low level of medical decision making. 
When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded 
 
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 31231 and 99304. Our reviewer says that in 
terms of CPT 31231, the procedure report describes endoscopy of right and left inferior turbinates; right and 
left mid turninates; nasopharnyx and eustachian tubes. For CPT 31231, diagnostic evaluation refers to 
employing a nasal/sinus endoscope to inspect the interior of the nasal cavity and the middle and superior 
meatus, the turbinates, and the sphenoethmoid recess. Therefore, this procedure cannot be verified. 
 
In terms of CPT 99304, this was reported with modifier -25, to identify a significant and separately identifiable 
evaluation and management service service the same physician or other qualified health care professional on 
the same day of the procedure or other service. However, the procedure report does not support a distinct 
procedural service. 
 
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 item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for 31231 and 99304. 
 
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.