Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical shoulder arthroscopy (procedure codes 29823, 29827) 
provided to the enrollee on December 7, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denied codes are not supported in the medical records submitted. 
 
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 29823: 
 
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]) 
 
CPT 29827: 
 
Arthroscopy, shoulder, surgical; with rotator cuff repair 
 
We asked our coder 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. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the procedure notes the labral tears 
were debrided extensively down to a stable rim of the labrum in the anterior, superior, and posterior regions of 
the joint. The undersurface of the rotator cuff was trimmed slightly in preparation for repair.   The subacromial 
space was decompressed and a soft tissue decompression and release of the coracoacromial ligament was 
performed. This supports that extensive debridement was performed on 3 or more discrete structures. 
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 actually rendered in this case. 
Additionally, the procedure note clearly states the rotator cuff was repaired anatomically utilizing an Arthrex 
SwiveLock anchor. Therefore, the records do support that CPT 29827: arthroscopy, shoulder surgical, with 
rotator cuff repair was actually rendered in this case. 
 
We looked at this coder'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 
surgical shoulder arthroscopy (procedure codes 29823, 29827) provided to the enrollee on December 7, 2021.  
 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.