Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 23420. We decided that the Plan does not have to pay for 29826.  
 
You asked the Plan to pay for surgical services (procedure code 23420 and 29826) rendered on June 23, 2022.. 
You say that this should be paid for. The Plan says that the records do not support the services billed. 
 
 
 We decided that the Plan has to pay for 23420.  
 
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 23420 is "Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)." 
 
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 23420. Our reviewer says that the procedure 
in detail cites there was a wide-open rotator cuff tear noted. Deltoid splitting approach was used to gain access 
to the subacromial space. A trough was made just medial to the greater tuberosity with a burr, and the rotator 
cuff freshened with a 15 blade. It was inserted into the trough with multiple #5 Ethibond sutures, obtaining 
good stability. Therefore, the records do support that CPT 23420 was rendered and supported 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 
23420.  
 
We also decided that the Plan does not have to pay for 29826. 
 
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 29826 is "Arthroscopy, shoulder, surgical; decompression of subacromial space with partial 
acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to 
code for primary procedure)."  
 
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 29826. Our reviewer says that the procedure 
in detail cites osteophytes of the anterior inferior acromion, including the distal inferior tip of the clavicle were 
removed with a bur. However, there was no indication of the coracoacromial ligament having been released. 
Therefore, the records do not support that CPT 29826 was rendered or supported 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 29826 have not been met. Therefore, we decided that the Plan does not have to 
pay for 29826. 
 
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.