Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical shoulder arthroscopy (procedure code 29822) provided to the 
enrollee on June 16, 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 denied code cannot be verified. 
 
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 29822 is "Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 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 rrecords do not support that CPT 
29822: arthroscopy, shoulder, surgical; debridement, limited 1 or 2 discrete structures (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 a separate and distinct procedure from CPT 29827: arthroscopy, shoulder surgical, with rotator 
cuff repair. The enrollee was being treated for incomplete rotator cuff tear or rupture of left shoulder; joint 
derangements of the left shoulder not elsewhere classified; other synovitis and tenosynovitis of the left 
shoulder; primary osteoarthritis of the left shoulder. He underwent a left shoulder arthroscopic rotator cuff 
repair of supraspinatus tendon; left shoulder hardware removal of prior suture knots; left shoulder arthroscopic 
distal clavicle excision on 6/16/22. The description of the procedure cites a shaver was used to debride the 
frayed labrum and open the rotator interval. The synovitis was debrided to a "healthy endpoint." This was done 
to open the rotator interval to remove the prior suture knots. In addition, the shaver and Arthrocare were used to 
fully debride the rotator interval and identify the coracoid. Given the subscapularis tear and decreased 
subcoracoid space, a decompression was completed. The burr was used to debride the posterior aspect of the 
coracoid opening the space. The shaver was used to debride the edge of the torn tendon and light decorticate 
the greater tuberosity footprint. This is needed to be performed for the rotator cuff repair to be performed. In 
addition, debridement-decompression was done to treat impingement and synovial inflammation and 
hypertrophy. 
 
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 29822) provided to the enrollee on June 16, 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.