Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left shoulder pain.
Treatment: Left Arthroscopy shoulder, surgical; debridement, extensive, 3 or more discrete structures.

The insurer denied Left Arthroscopy shoulder, surgical; debridement, extensive, 3 or more discrete structures.  The determination is upheld.

This is a female patient with a complaint of left shoulder pain. She failed conservative treatment for a rotator cuff tear and opted to undergo elective left shoulder arthroscopic surgery for rotator cuff repair, biceps tenodesis, and extensive debridement. The patient's health plan denied coverage of the extensive debridement of 3 structures (current procedural terminology [CPT] 29823) with a determination that this was not medically necessary. At issue in this case is the medical necessity of the extensive debridement portion of this shoulder operation.

The requested health service/treatment of left shoulder arthroscopy with extensive debridement of 3 or more discrete structures was not medically necessary for this patient. The provided medical records document that this patient underwent elective arthroscopic shoulder surgery. The provided operative dictation form that date details an arthroscopic rotator cuff repair and biceps tenodesis. The care rendered in this case was consistent with the current standard of care and with the recommendations of the peer-reviewed literature as documented by Lim and colleagues in 2020. The patient underwent extensive debridement of 3 discrete structures in the gleno-humeral joint, however, the dictation is contradictory. Initially, the report states that the non-meniscoid superior labrum was stable to probing. In addition, the report states that the was normal articular cartilage and a normal posterior labrum. The report then states that "Arthroscopic debridement of 3 or more discrete structures was performed during this procedure including: humeral articular cartilage, biceps tendon, biceps anchor complex, labrum, articular side of the rotator cuff, bursar side of the rotator cuff, and sub-acromial bursa." Debridement of the humeral articular cartilage and labrum would not be medically necessary if these structures were normal as previously stated in the operative report - this is contradictory. According to the National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, CPT codes 29824 (Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)), 29827 (Arthroscopy, shoulder, surgical; rotator cuff repair), and 29828 (Arthroscopy, shoulder, surgical; biceps tenodesis) may be reported separately with CPT code 29823 if the extensive debridement is performed in a different area of the same shoulder." Since a biceps tenodesis and rotator cuff repair were both performed for this patient, the operative report does not detail debridement of 3 or more structures other than the biceps tendon and supraspinatus tendon which were already coded for 29828 and 29827, respectively. More specifically, the bursal and articular sided debridement of the rotator cuff and debridement of the biceps tendon and biceps anchor complex do not represent separate, discrete structures that would qualify for extensive debridement according to the NCCI rules for Medicare services.