Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure codes 27514, 27835, 29876) provided to 
the enrollee on September 28, 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 records do not support the services billed. 
 
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 
the denied codes is: 
 
CPT 27514: 
 
Open treatment of femoral fracture, distal end, medial or lateral condyle, includes internal fixation, when 
performed 
 
CPT 27535: 
 
Open treatment of tibial fracture, proximal (plateau); unicondylar, includes internal fixation, when performed 
 
CPT 29876: 
 
Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral) 
 
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 records do support that CPT 
29876: arthroscopy, knee, surgical, synovectomy, major 2 or more compartments (e.g., medial or lateral) was 
rendered in this case. The procedure in detail cites using a combination of an arthroscopic shaver and 
radiofrequency wand in order to treat the significant and diffuse/profuse transient synovitis in all 
compartments, specifically in the lateral compartment, patellofemoral compartment, and the infrapatellar 
notch/anterior fat pad.  
 
Additionally, the records also support that CPT 27514: open treatment of femoral fracture, distal end, medial or 
lateral condyle, includes internal fixation when performed was rendered in this case. The procedure in detail 
cites the Anika TactoSet delivery system was utilized delivering the engineered calcium phosphate in order to 
provide internal fixation of the subchondral impaction fracture. After hardening of the substrate, the application 
was removed and the stabilization hardware and closed the incision.  
 
Finally, the records also support that CPT 27535: open treatment of tibial fracture, proximal (plateau); 
unicondylar, includes internal fixation when performed was rendered in this case. The procedure in detail cites 
the Anika TactoSet delivery system was utilized delivering the engineered calcium phosphate in order to provide internal fixation of the subchondral impaction fracture. After hardening of the substrate, the application 
was removed and the stabilization hardware and closed the incision. 
 
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 services (procedure codes 27514, 27835, 29876) provided to the enrollee on September 28, 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.