Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (codes 23420-RT, 23420-AS-RT, 
29823-59-RT, and 29823-AS-59-RT) provided on May 3, 2022. 
 
You asked the Plan to pay for codes 23420-RT, 23420-AS-RT, 29823-59-RT, and 29823-AS-59-RT. You say 
that the medical records support the billing of codes 23420-RT, 23420-AS-RT, 29823-59-RT, and 29823-AS-
59-RT provided on May 3, 2022. The Plan denied your request. The Plan says the medical records do not 
support the billing of codes 23420-RT, 23420-AS-RT, 29823-59-RT, and 29823-AS-59-RT provided on May 
3, 2022. 
 
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 code 23420 is Reconstruction of complete shoulder (rotator) 
cuff avulsion, chronic (includes acromioplasty). The definition of code 29823 is Arthroscopy, shoulder, 
surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, 
glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]). 
 
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 codes 23420-RT, 23420-AS-RT, 29823-59-RT, and 29823-
AS-59-RT. Our reviewer says that the medical records do not support the billing of codes 23420-RT, 23420-
AS-RT, 29823-59-RT, and 29823-AS-59-RT provided on May 3, 2022. Our reviewer found the enrollee was 
being treated for right shoulder rotator cuff tear; right shoulder impingement; and right shoulder 
acromioclavicular joint arthritis. She underwent right shoulder open rotator cuff reconstruction; extensive 
partial synovectomy of the glenohumeral joint; subacromial and subdeltoid bursectomy, coracoacromial 
ligament excision, and anterior acromioplasty; acromioclavicular joint and lateral clavicle arthroscopic 
excision; and regional suprascapular nerve block on May 3, 2022.  
 
In regards to code 29823 (arthroscopy, shoulder, surgical debridement, extensive, 3 or more discrete structures 
(e.g., humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps 
anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, 
subacromial bursa, foreign body[ies]); the procedure report corroborates she underwent a diagnostic 
arthroscopy in which the glenohumeral joint was visualized with marked synovitis and inflammation. This was 
debrided back with the shaver. The posterior labrum had mild fraying and it was debrided. However, detailed 
documentation is not evident regarding any more than two structures having been debrided during this 
arthroscopic procedure. (Rotator cuff debridement was only a portion of preparation for cuff repair.) Therefore, 
the documentation does not support procedure codes 29823-59-RT or 29823-AS-59-RT.  
 
With regard to code 23420 (reconstruction of complete shoulder (rotator) cuff avulsion (includes 
acromioplasty), the deltoid was split in line with its fibers at the anterolateral aspect of the acromion. The 
frayed edges of the cuff were debrided and was mobilized with #1 Ti-Cron suture posteriorly. The cuff was 
repaired side-to-side. At the articular surface greater tuberosity junction, curetting was performed and 5.5 
Biocorkscrew was placed. Two sutures were placed through the cuff, two more anterior and two more 
posterior. These were tied down, crisscrossed out laterally and PushLocks were applied out laterally. However, 
during the diagnostic arthroscopy, the rotator cuff tear was easily identified and is noted to be a large 
supraspinatus rotator cuff tear. There is no indication that the infraspinatus or subscapularis fibers were torn. 
The repair does not indicate that all 3 separate portions of the rotator cuff were avulsed and repaired. Therefore, 
the documentation does not support procedure codes 23420-RT and 23420-AS-RT. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 23420-RT, 23420-AS-RT, 29823-59-RT, and 29823-AS-59-RT have not 
been met. Therefore, we decided that the Plan does not have to pay for the surgical services (codes 23420-RT, 
23420-AS-RT, 29823-59-RT, and 29823-AS-59-RT) provided on May 3, 2022.