Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure code 20680, 27130) rendered on 
December 16, 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 20680: 
 
Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) 
 
CPT 27130: 
 
Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without 
autograft or allograft 
 
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 records do support that CPT 
20680 and CPT 27130 were rendered in this case. The procedure in detail cites the head of the screw identified 
and the screw was backed out and removed. Attention was turned to the hip. The entrance of the femoral rod 
was identified and the locking screw was loosened. Attention was then turned to the lag screw and each of 
those was removed in turn. The femoral rod was backed out and removed without difficulty. Therefore, CPT 
20680 was supported.  
 
Additionally, the procedure in detail cites femur was retracted anteriorly and the acetabulum was exposed. The 
labrum and soft tissue of the fovea was resected and the acetabulum was reamed with progressively larger 
reamers to a size 55. A 56 cup was then inserted. The screw hole was drilled and filled with the 25mm lag 
screw. Position was checked and the implant was noted to fit securely. A 40 x 56mm 10-high wall liner was 
inserted and noted to lock in place. Attention was turned to the femur and the peri-femoral tissues were injected 
with Exparel. The femur was then broached with progressively larger broaches and to a size 11. With the 
broach in place, the femoral head was trialed and a +6 neck was felt to be most appropriate. The trials were 
removed and the permanent 11 standard offset femoral stem was inserted and re-trialed with the +6 femoral 
head. Therefore, the records also support CPT 27130. 
 
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 (procedure code 20680, 27130) rendered on December 16, 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.