Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for CPT 29823. We decided that the Plan does not have to pay for CPT 
23395.  
 
You asked the Plan to pay for surgical services (procedure codes 23395, 29823) provided to the enrollee on 
August 3, 2022.. You say that this should be paid for. The Plan says that the denied codes are not supported by 
the medical records submitted. 
 
We decided that the Plan has 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 "Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, 
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 procedure 
report details the biceps tendon had significant partial-thickness tearing and this was debrided first on its 
inferior surface then superior surface. There was moderate tearing of the anterior labrum and this was debrided 
from the 1 down to the 5 oclock position. The subscapularis tendon had thickness tearing near its superior 
border and was debrided. There was a moderate amount of tearing of the posterior labrum and was debrided. 
Therefore, the records do support that CPT 29823: arthroscopy, shoulder, surgical, debridement, extensive 3 or 
more discrete structures (e.g., 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]) was rendered in this case. 
 
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 have been met. Therefore, we decided that the Plan has to pay for 
29823.  
 
We also decided that the Plan does not have to pay for CPT 23395. 
 
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 23395 is "Muscle transfer, any type, shoulder or upper arm; single." 
 
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 23395. Our reviewer says that the procedure 
details a separate surgical incision over the axillary was made. The biceps tendon was shortened and was 
sutured to the intramedullary canal and the sutures exit distally on either biceps tendon through the anterior 
humerus. The biceps was reduced into the intramedullary canal and sutures on top of the biceps nicely 
juxtaposing the biceps to the anterior humerus. This evidences a tenodesis opf the biceps tendon which is 
typically coded as 23430. Therefore, the records do not support that CPT 23395: muscle transfer, any type, 
shoulder or upper arm, single was rendered in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 23395 have not been met. Therefore, we decided that the Plan does not have to 
pay for 23395. 
 
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.