Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for CPT 29826 and CPT 29827. We decided that the Plan does not have to pay for CPT 29823.

You asked the Plan to pay for the denied codes. 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 29826 and 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 the denied codes is:

CPT 29826: 

surgical shoulder arthroscopy, with decompression of subacromial space with a partial acromioplasty, with or without coracoacromial ligament (arch) release (listed separately in addition to code for primary procedure)

CPT 29827: 

surgical shoulder arthroscopy, with rotator cuff repair

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 29826 and CPT 29827. Our reviewer says that the medical records support these two codes Our physician reviewer found that a detailed review of the operative report reveals evidence that CPT codes 29826 and 29827 were adequately documented as having been performed/were performed. Regarding CPT 29826; the provider adequately detailed an acromioplasty/decompression having been performed. A detailed review of the operative report reveals reasonable and clear documentation that this coded procedure was performed as per "general correct coding policies." Regarding CPT 29827; the provider adequately detailed an arthroscopic surgery with rotator cuff repair having been performed. A detailed review of the operative report reveals reasonable and clear documentation that this coded procedure was performed as per "general correct coding policies." In further detail, the provider extended the lateral arthroscopic portal to perform the cuff repair itself. The portal extension in itself did not constitute a so-called 'mini-open' or open repair, based on the description as documented.) The described procedure was performed and adequately documented as per "general correct coding policies."

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT 29826 and CPT 29827 have been met. Therefore, we decided that the Plan has to pay for CPT 29826 and 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 29823 is "surgical shoulder arthroscopy with extensive debridement."

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 medical records do not support this code. Our physician reviewer found that a detailed review of the operative report does not reveal that CPT 29823 was performed as per "general correct coding policies." The NCCI guidelines indicate that physicians "must avoid upcoding." Considering that there was no reasonably detailed documentation of significant degree/quantity of multi-compartment and/or extensive debridement performed on the operative report; CPT code 29823 was not reasonably documented as having been performed. CPT 29823 is found to not reflect the service provided because the requested procedure does not fully meet the guidelines for shoulder arthroscopy with "extensive" debridement.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT 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.