Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 29827 and 23430. We decided that the Plan does not have to pay for 
29823 and 29824.  
 
You asked the Plan to pay for the surgical services (29827, 29823, 23430, and 29824) provided on September 
20, 2022. You say that the claim should be paid. The Plan says that the services are not supported by the 
records. 
 
We decided that the Plan has to pay for 29827 and 23430.  
 
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 29827 is arthroscopy, shoulder, surgical; with rotator cuff 
repair. The definition of code 23430 is tenodesis of long tendon of biceps. 
 
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 to pay for 92827 and 23430. Our reviewer says that the 
medical records do support the use of procedure code 29827 as the rotator cuff tear was repaired and the 
description was correct with the procedure code. The medical records do support the use of procedure code 
23430 as the long tendon biceps was repaired. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of   have been met. Therefore, we decided that the Plan has to pay for 29827 and 
23430.  
 
We also decided that the Plan does not have to pay for 29823 and 29824. 
 
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]). The definition of code 29824 is 
arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure). 
 
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 to pay for 29823 and 29824. Our reviewer says that the 
medical records do not support the use of procedure code 29823 as medical documentation only lists two (2) 
debridements not three (3). There is a more appropriate code for this description. The medical records do not 
support the use of procedure code 29824 as the procedure was not performed at all in the description of the 
procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 29823 and 29824 have not been met. Therefore, we decided that the Plan does 
not have to pay for 29823 and 29824. 
 
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.