Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 25575 and 20580. We decided that the Plan does not have to pay for 
25295.  
 
You asked the Plan to pay for surgical services provided to the enrollee on June 6, 2022.. You say that this 
should be paid for. The Plan says that the records do not support the services billed. 
 
In this case, the CPT manual definition of the denied codes is: 
 
CPT 20680: 
 
Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) 
 
CPT 25295:  
Tenolysis, flexor or extensor tendon, forearm and/or wrist, single, each tendon 
 
CPT 25575: 
 
Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius AND 
ulna 
 
We decided that the Plan has to pay for 25575 and 20580.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 25575 and 20680. Our reviewer says that the 
operative course cites there was a malunion noted with dorsal angulation of the distal radius. The plate was 
selected to traverse the fracture and holes were drilled in the proximal plate in the radius shaft and then the 
distal aspect of the distal radius was examined. The distal radius was very dorsally tilted and an osteotomy was 
performed on the distal radius. Screws were inserted to stabilize the distal radius. Final fluoroscopic imaging 
showed good anatomic alignment and correction of the dorsal tilt of the distal radius. Also noted, was blunt 
dissection was then carried down to the ulna shaft. The fracture site was debrided, irrigated and reduced 
temporarily. The ulna plate was cut to size and fixed temporarily with a lobster claw. Holes were drilled and 
measured then locking screws were inserted across the fracture site. Therefore, CPT 25575 is supported in the 
records. In terms of CPT 20680, the operative course cites that the Acumed screwdriver was brought onto the 
plate to remove the volar plate and the hardware was removed in its entirety including the plate and all 
screws. This was performed separately and was a large piece of hardware and screws distinct from the 
underlying malunion to be repaired. Therefore, the records do support that CPT 20680 was rendered 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 
25575 and 20580.  
 
We also decided that the Plan does not have to pay for 25295. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 25295. Our reviewer says that the operative 
course cites a 9cm incision was made volarly over the FCR tendon. Blunt dissection was then performed and 
carried down to the FCR tendon as well as around the FPL tendon and palmaris longus. Extensive tenolysis of 
these three tendons was performed. However, this was essentially performed to allow access to the radial 
malunion for repair of same. Therefore, the records do not support that CPT 25295: tenolysis, flexor or 
extensor tendon, forearm and/or wrist, single, each tendon is a separate and distinct procedure from CPT 
25400: repair of nonunion or malunion, radius OR ulna without graft (e.g., compression technique) was 
rendered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 25295 have not been met. Therefore, we decided that the Plan does not have to 
pay for 25295. 
 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.