Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical shoulder arthroscopy provided to the enrollee on July 6, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. 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 
code 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 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 enrollee was being treated for a 
right moderate-sized full-thickness tear of the supra and leading infraspinatus with retraction to the mid 
humeral head; medial subluxation and fraying of the biceps tendon; and chronic refractory subacromial 
impingement. He underwent an arthroscopic rotator cuff repair; arthroscopic subacromial decompression; open 
subpectoral biceps tenodesis; gentle manipulation under anesthesia with arthroscopic lysis of adhesions; 
debridement of the superior labrum and anterior labrum; and injection of PRP (platelet-rich plasma) on 
7/6/22. The procedure note stated the labrum was debrided circumferentially. A shaver was inserted, and 
chondroplasty was performed of the humeral head. There was significant and extensive bursitis in the 
subacromial space and a bursectomy was performed with the shaver. The bur was used to perform an 
acromioplasty co-planing the undersurface of the acromion so that it was smooth and flush. 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 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 provided to the enrollee on July 6, 2022.  
 
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.