Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for surgical services provided to the enrollee on November 19, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. 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 
the denied codes is: 
 
CPT 28090: 
 
Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (eg, cyst or ganglion); foot 
 
CPT 28122: 
 
Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or 
bossing); tarsal or metatarsal bone, except talus or calcaneus 
 
CPT 28296: 
 
Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with distal metatarsal 
osteotomy, any method 
 
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 operative report supports the 
codes were rendered. CPT 28090 is supported by - capsular tissue was noted to be caseating, hypertrophied and 
edematous, consistent with an inflammatory process. The redundant and excessive synovial tissue was then 
resected from the 1st metatarsophalangeal joint. CPT 28122 is supported by - multiple loose bodies of bone and 
cartilage were identified within the dorsal and lateral joint spaces and were sharply excised. Upon examination 
of the head of the first metatarsal and base of the phalanx, it was noted that excessive hypertrophic bone 
formation was present dorsally, medially, and laterally with lipping and sharp areas. CPT 28296 is supported 
by - the metatarsal head was delivered into the wound. Utilizing an osteotome and mallet, the hypertrophied 
medial epicondyle was excised. The bone was examined and rasped smooth. Therefore, the records do support 
that the codes, CPT 28090: excision of lesion, tendon, tendon sheath or capsule (including synovectomy) (e.g., 
cyst or ganglion) foot; CPT 28122: partial excision (cauterization, saucerization, sequestrectomy, or 
diaphysectomy) bone (e.g., osteomyelitis or bossing), tarsal or metatarsal bone, except talus or calcaneus; CPT 
28296: correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed, with distal 
metatarsal osteotomy any method, were actually 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 services provided to the enrollee on November 19, 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.