Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 26442. We decided that the Plan does not have to pay for 26123.  
 
You asked the Plan to pay for surgical services provided to the enrollee on November 17, 2021.. 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 26442.  
 
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 26442 is "Tenolysis, flexor tendon; palm AND finger, each tendon." 
 
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 26442. Our reviewer says that the detailed 
operative note cited a distal tenolysis was necessary for the FDS and the FDP tendon in the finger and also in 
the palm. Therefore, the records do support that CPT 26442: tenolysis, flexor tendon, palm AND finger, each 
tendon- 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 
26442.  
 
We also decided that the Plan does not have to pay for 26123. 
 
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 26123 is "Fasciectomy, partial palmar with release of single digit including proximal interphalangeal 
joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft)." 
 
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 26123. Our reviewer says that the records do 
not support that CPT 26123: fasciectomy, partial palmar release of single digit including proximal 
interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes 
obtaining graft)- was rendered in this case. The detailed operative note cited that a distal tenolysis was 
necessary for the FDS and the FDP tendon in the finger and also in the palm. There was on documentation of 
fasciectomy or partial palmar release performed outside of this. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 26123 have not been met. Therefore, we decided that the Plan does not have to 
pay for 26123. 
 
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.