Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 69990-59 billed for date of service August 4, 2022. 
 
You asked the Plan to pay for code 69990-59. You say that procedure code 69990 was a necessary part of this 
surgery. You used a 59 modifier to show the separate service. The Plan denied your request. The Plan says the 
billing of code 69990-59 is not supported. This code is considered part of code 61781 and can't be separately 
reimbursed. The medical records do not support that code 69990 was distinct or independent from 61781. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 code 69990-59 Our reviewer says that the 
use of the 59 modifier with code 69990 is not supported in the medical record. Our physician reviewer found  
that the operative report does not include sufficient documentation to confirm separate reporting for 69990 and  61781. Per NCCI Policy "codes 61781-61783 are Add-on Codes (AOCs) describing computer-assisted 
navigational procedures of the cranium or spine. Medicare payment policy does not allow code 69990 
(Microsurgical technique requiring use of operating microscope) to be reported with these codes unless code 
69990 is reported with another code that meets the requirements of the Centers of Medicare & Medicaid 
Services (CMS) Internet-Only Manual, Publication 100- 04, Medicare Claims Processing Manual, Chapter 
12 (Physicians/Nonphysician Practitioners), Section 20.4.5. This manual section limits the separate payment 
for code 69990 to a small number of procedures. In these situations, providers/suppliers may report modifier 59 
or XU with code 69990 to indicate that the procedure described by code 69990 was performed for a procedure 
other than the computer-assisted navigation on the same date of service".  The operative report documents "the 
operating microscope was brought into the field. An 1/2 inch cottonoid covered with Ioban was slid over the 
lateral cerebellar hemisphere to visualize the tubercle and arachnoid of the CP angle cistern. This arachnoid 
was opened to permit additional release of CSF and the 7th nerve complex was visualized. After excellent 
cerebellar relaxation, attention was turned to the petrosal vein, of which 2 branches were cauterized and 
divided. This permitted visualization of the superior aspect of the trigeminal nerve, which was noted to be 
contacted by a loop of the superior cerebellar artery adjacent to the root entry zone. The arachnoid between the 
SCA and superior aspect of the trigeminal nerve was divided and in order to permit mobilization of the SCA 
along its course. In addition, a vein with 2 branches, containing calcification, was prominently on the dorsal 
surface of the trigeminal nerve. This was completely dissected away from the nerve in order to cauterize and 
divide it. Two Teflon pledgets were then placed between the artery and nerve in order to prevent additional 
contact of the SCA along the trigeminal nerve including its entry at the brainstem".  In this case, documentation 
does not support, CPT 69990 was performed for a procedure other than the computer-assisted navigation on the 
same date of 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 code 69990-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 69990-59 billed for date of service August 4, 2022.