Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 28555 and 28615. We decided that the Plan does not have to pay for 
27696 and 28465.  
 
You asked the Plan to pay for surgical services (procedure codes 27696, 28465, 28555, 28615) provided to the 
enrollee on May 15, 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 28555 and 28615.   
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 28555 (Open treatment of tarsal bone 
dislocation, includes internal fixation, when performed) and CPT 28615 (Open treatment of tarsometatarsal 
joint dislocation, includes internal fixation, when performed). Our reviewer says that these codes are supported 
by the medical records. 
 
In terms of CPT 28555, the procedure note cites plate was positioned starting at the distal end of the calcaneus, 
spanning the cuboid, after the cuboid was reduced, restoring the length of the lateral column and along the 4th 
metatarsal shaft and 4th tarsometatarsal articulation. The plate was positioned and verified under fluoroscopy. 
The 5th metatarsal articulation with the cuboid was still subluxing and another internal fixator was placed. The 
subluxation of the middle cuneiform was identified, and a screw was placed going through the plate from the 
cuboid into the middle cuneiform to severe that alignment. Another dorsal plate was placed to secure the 
subluxation of the middle cuneiform to the 3rd metatarsal. This was all done through the lateral-based incision. 
The documentation does support tarsal bone dislocation or treatment. Therefore, the records do support that 
CPT 28555: open treatment of tarsal bone dislocation, includes internal fixation, when performed was rendered 
in this case. 
 
In terms of CPT 28615, the procedure note cites the plate was positioned starting at the distal end of the 
calcaneus, spanning the cuboid, after the cuboid was reduced, restoring the length of the lateral column and 
along the 4th metatarsal shaft and 4th tarsometatarsal articulation. The records do support that CPT 28615: 
open treatment of tarsometatarsal joint dislocation, includes internal fixation, when performed 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 
28555 and 28615.  
 
We also decided that the Plan does not have to pay for 27696 and 28465. 
 
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 27696 (Repair, primary, disrupted ligament, 
ankle; both collateral ligaments) and CPT 28465 (Open treatment of tarsal bone fracture (except talus and 
calcaneus), includes internal fixation, when performed, each). Our reviewer says that the services are not 
supported in the medical records. 
 
In terms of CPT 27696, the records do not support that repair, primary, disrupted ligament, ankle; both 
collateral ligaments was rendered in this case. The procedure note cites a small avulsion fracture was repaired 
off the distal fibula. Reduction was performed. The ligaments were repaired coming off the fibular head going 
to the talar body which were avulsed off the talar body. A plate was used to severe the small fragment of bone 
with ligament complex back to the talar body. However, these ligaments were not documented to be the 
collateral ligaments. In addition, they were connected to the avulsed bont fragment itself. 
 
In terms of CPT 28465, the procedure note cites plate was positioned starting at the distal end of the calcaneus, 
spanning the cuboid, after the cuboid was reduced, restoring the length of the lateral column and along the 4th 
metatarsal shaft and 4th tarsometatarsal articulation. The plate was positioned and verified under fluoroscopy. The 5th metatarsal articulation with the cuboid was still subluxing and another internal fixator was placed. The 
subluxation of the middle cuneiform was identified, and a screw was placed going through the plate from the 
cuboid into the middle cuneiform to severe that alignment. Another dorsal plate was placed to secure the 
subluxation of the middle cuneiform to the 3rd metatarsal. This was all done through the lateral-based incision. 
The documentation does not support tarsal bone fracture treatment without the calcaneus. Therefore, the 
records do not support that CPT 28465: open treatment of tarsal bone fracture (except talus and calcaneus), 
includes internal fixation, when preformed 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 27696 and 28465 have not been met. Therefore, we decided that the Plan does 
not have to pay for 27696 and 28465. 
 
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.