Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for 29827. We decided that the Plan does not have to pay for CPT 29823.
You asked the Plan to pay for the services. 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 CPT 29827.
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 CPT code 29827 is "surgical shoulder arthroscopy, with rotator cuff repair, with increased procedural services." 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 29827. Our reviewer says that the records support this code. Our physician reviewer found that the procedure notes indicate that due to the massive rotator cuff tendon tear size, the procedure required approximately an hour longer surgical time than in a more typical/standard rotator cuff repair. Therefore, CPT 29827 was supported as having been both applicable and rendered during the surgical procedure on 10/20/20. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 29827 have been met. Therefore, we decided that the Plan has to pay for CPT 29827.
We also decided that the Plan does not have to pay for CPT 29823.
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 CPT code 29823 is "surgical shoulder arthroscopy, with extensive debridement, including 3 or more discrete structures (humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])." 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 29823. Our reviewer says that the records do not support this code. Our physician reviewer found that the operative note on 10/2020 states that an extensive debridement was performed. The diagnostic arthroscopy found the bicipital stump attached to the superior labrum was extensively diseased and needed to be debrided. Any other debridement and/or microfracture procedures are done as part of rotator cuff tendon repair. Therefore, there was no reasonable documentation of applicable extensive rendering of debridement reflective of 29823 (debridement of 3 separate structures separate from being an inherent portion of cuff tendon repairs). Overall debridement was limited (and 29822 was likely applicable.) We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 29823 have not been met. Therefore, we decided that the Plan does not have to pay for CPT 29823.
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.