Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure code 27870 and 28725) rendered on 
December 1, 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 records do not support the services billed. 
 
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 27870: 
 
Arthrodesis, ankle, open 
 
CPT 28725: 
 
Arthrodesis; subtalar 
 
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 description of the procedure cites 
a stab incision was made on the plantar aspect of the right foot and inserted a guidewire into the correct starting 
position on the calcaneus. The guidewire was advanced and the canal opened. A ball tip was then passed. This 
was reamed sequentially and then placed a 12 x 300 mm hindfoot fusion nail. This not only aligned the ankle, 
but also eliminated hindfoot plantar flexion secondary to the foot drop. The nail was interlocked twice distally 
and once proximally. The procedure was performed in a stab incision with subsequent fusion nail was placed. 
Therefore, the records do support that CPT 27870: arthrodesis, ankle, open was rendered in this case. 
Additionally, the description of the procedure cites a stab incision was made on the plantar aspect of the right 
foot and inserted a guidewire into the correct starting position on the calcaneus. The guidewire was advanced 
and the canal opened. A ball tip was then passed. This was reamed sequentially and then placed a 12 x 300 mm 
hindfoot fusion nail. This not only aligned the ankle, but also eliminated hindfoot plantar flexion secondary to 
the foot drop. The nail was interlocked twice distally and once proximally. The documentation does support 
that the subtalar joint was fused in this procedure. The calcaneus/hindfoot were fused. The nail length further 
supports that the calcaneus/talus appear to have been fused, including correcting the dropfoot. Therefore, the 
records do support that CPT 28725: arthrodesis subtalar was 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 services (procedure code 27870 and 28725) rendered on December 1, 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.