Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.  Medicare guidance says Field Name & Description: Global Surgery &This field provides the postoperative time frames that apply to payment for each surgical procedure or another indicator that describes the applicability of the global concept to the service. ZZZ = Code related to another service and is always included in the global period of the other service. You can find the guidance in the Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and Coding Requirements, SEC-50.6.  Medicare guidance says an add-on code is a HCPCS/CPT code that describes a service that, with one exception (see CR7501 for details), is always performed in conjunction with another primary service. An add-on code with one exception is eligible for payment only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on code with one exception is never eligible for payment if it is the only procedure reported by a practitioner. Add-on codes may be identified in three ways: 1. The code is listed in this CR or subsequent ones as a Type I, Type II, or Type III add-on code. 2. On the Medicare Physician Fee Schedule Database, an add-on code generally has a global surgery period of "ZZZ". 3. 3.In the CPT Manual an add-on code is designated by the symbol "+". The code descriptor of an add-on code generally includes phrases such as "each additional" or "(List separately in addition to primary procedure)." CMS has divided the add-on codes into three groups to distinguish the payment policy for each group. 1). Type I - A Type I add-on code has a limited number of identifiable primary procedure codes. The CR lists the Type I add-on codes with their acceptable primary procedure codes. A Type I add-on code, with one exception, is eligible for payment if one of the listed primary procedure codes is also eligible for payment to the same practitioner for the same patient on the same date of service. Claims processing contractors must adopt edits to assure that Type I add-on codes are never paid unless a listed primary procedure code is also paid. You can find the guidance in the CMS.GOV Add-on Code Edits.   Medicare guidance says for Add-on code 77003 appropriate Primary Codes 61050, 61055, 62267, 62273, 62280, 62281, 62282, 62284, 64449, 64510, 64517, 64520, 64610, 96450. July 2021 National Physician Fee Schedule Relative Value File: CPT code 77003, Global days "ZZZ". you can find the guidance in the July 2021 National Physician Fee Schedule Relative Value File.  Medicare guidance says the A/B MACs (A) must provide a listing of the required data elements, including a brief explanation to providers and suppliers. A/B MACs (A) must educate providers regarding the distinction between submissions which are not considered claims, but which are returned to provider (RTP) and submissions which are accepted by Medicare as claims for processing but are not paid. Claims may be accepted as filed by Medicare systems but may be rejected or denied. Unlike RTPs, rejections and denials are reflected on RAs. Denials are subject to appeal, since a denial is a payment determination. Rejections may be corrected and resubmitted. You can find the guidance says Medicare Claims Processing Manual Chapter 1 - General Billing Requirements Section 70.2.3.2 and 80.3.1.  If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.