Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the shoulder arthroscopy (CPT code 29823-RT) provided on November 
8, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says that the operative report did not include documentation of a surgical shoulder arthroscopy with 
extensive debridement for three (3) or more discrete structures (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]); therefore, 
this code cannot be verified. 
 
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 service. Our reviewer found the November 8, 2021, 
operative report did support that there was extensive debridement for three (3) or more discrete structures. 
There was some fraying of the superior labrum as well as the anterior and posterior labrum. This was then 
debrided. The subscapularis tendon was inspected and there was a tear of the subscapularis tendon along the 
superior aspect. This was debrided and repaired back to its anatomic footprint using 1 SwiveLock anchor. The 
enrollee had a mild to moderate degree of subacromial bursitis. A radiofrequency wand as well as a shaver was 
used to debride the subacromial space. The enrollee did have a small subacromial spur, and this was debrided 
back to a flat surface. The radiofrequency wand as well as a shaver was used to debride the bursa. The rotator 
cuff was inspected and found to have a tear of the supraspinatus tendon. The enrollee did have some 
delamination of the rotator cuff tendon. This was able to be debrided to a healthy border. Therefore, the 
shoulder arthroscopy (CPT 29823-RT) on November 8, 2021, is supported in the medical records provided. 
 
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 service have been met. Therefore, we decided that the Plan has to pay for 
the shoulder arthroscopy (CPT code 29823-RT) provided on November 8, 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.