Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical shoulder arthroscopy (procedure code 29823) provided to the 
enrollee on May 10, 2022. 
 
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 operative report did not include sufficient documentation to support this code. 
 
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 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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the enrollee was being treated for 
primary osteoarthritis of the right shoulder. He underwent an arthroscopic rotator cuff repair; extensive 
debridement of the synovitis within the glenohumeral joint as well as the degenerative labrum and the partial 
biceps tear as well as bursectomy in the subacromial bursa; subacromial decompression with coplaning of the 
clavicle on 5/10/22. The procedure details using the inside-out technique, an anterior portal was created and 
through this a Mitek radiofrequency ablation tool and full synovial resector, a synovectomy was carried out. 
Debridement of the superior labrum was carried out and debridement of the biceps tendon was carried out. 
Next, the arthroscope was switched from the posterior portal to the subacromial space. A lateral portal was 
created and through this, with Mitek radiofrequency ablation tool and full radius synovial resector, a 
bursectomy was carried out. Therefore, the records do support that CPT 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]) was 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 shoulder arthroscopy (procedure code 29823) provided to the enrollee on May 10, 2022.  
 
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.