Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 20610. We decided that the Plan does not have to pay for G0289.  
 
You asked the Plan to pay for surgical services (procedure codes 20610 and G0289) provided to the enrollee on 
February 15, 2022.. You say that this should be paid for. The Plan says that these denied codes are inclusive to 
another billed code. 
 
We decided that the Plan has to pay for 20610.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 20610 is "Arthrocentesis, 
aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound 
guidance." 
 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 20610. Our reviewer says that the enrollee 
was being treated for derangement of the posterior horn of the medial meniscus due to old tear or injury of the 
right knee; derangement of other lateral meniscus due to old tear or injury of the right knee. He underwent a 
right knee arthroscopy with partial medial and lateral meniscectomy, removal of loose body with 
chondroplasty, debridement lower extremity, and injection of platelet-rich plasma on 2/15/22. The procedure 
details state that the portal sites were irrigated and closed. There was then an injection of platelet-rich plasma 
through a superior lateral portal. This was a separate and distinct procedure. Therefore, the records do support 
CPT 20610. 
 
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 
20610.  
 
We also decided that the Plan does not have to pay for G0289. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of Healthcare Common 
Procedure Coding System (HCPCS) G0289 is "Arthroscopy, knee, surgical, for removal of loose body, foreign 
body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy 
in a different compartment of the same knee." 
 
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 G0289. Our reviewer says that the procedure 
details state that (during the meniscectomies) the cartilaginous defect was debrided. Removal of the (non-
previously identified and not detailed as to the source of the "loose body") only occurred as part of the routine 
irrigation at procedure's end. This would not be considered a separate procedure. Therefore, the records do not 
support HCPCS G0289. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of G0289 have not been met. Therefore, we decided that the Plan does not have to 
pay for G0289. 
 
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.