Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for billed code 29879. We decided that the Plan does not have to pay for billed code 29876-59.
You asked the Plan to pay for the services provided. The Plan says that the billed services cannot be verified.
We decided that the Plan has to pay for the arthroscopy procedure as identified by billed code 29879.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 29879 is Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture.
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 services provided. Our physician reviewer found that the enrollee was being treated for right knee complex medial meniscus tear; major 3-compartment synovitis; chondromalacia, medial femoral condyle; and chondromalacia patellae. She has a many month's history of right knee buckling and recurrent effusions that have failed to gain relief with conservative means. Recommendation was to explore this further. MRI revealed a complex tear to the posterior horn of the medial meniscus with large effusion and large chondral injury to her medial femoral condyle and patellofemoral joint. Based on this internal derangement and the facet she was having mechanical symptoms, surgery was recommended. Procedure documents show a major 3-compartment synovectomy was performed of the patellofemoral, medial, and lateral compartments. The femoral condyle did have a large chondral injury in relation in the weightbearing zone. Therefore, a burr arthroplasty (includes abrasion chondroplasty) was performed to the medial femoral condyle, bringing it back to a healthy, stable cartilaginous rim. The documentation supports that code 29879 was performed, and supported, as per the operative note. 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 services provided have been met. Therefore, we decided that the Plan has to pay for the arthroscopy procedure as identified by billed code 29879.
We also decided that the Plan does not have to pay for the arthroscopy procedure as identified by billed code 29876-59.
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.
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the arthroscopy procedure as identified by billed code 29876-59.
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.