Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure codes 23430, 29823, 29824, 29827) 
provided to the enrollee on May 20, 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 23430: 
 
Tenodesis of long tendon of biceps 
 
CPT 29823: 
 
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]) 
 
CPT 29824: 
 
Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) 
 
CPT 29827: 
 
Arthroscopy, shoulder, surgical; with rotator cuff repair 
 
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 operative note details cite he was 
found to have significant tearing of the anterior and superior labrum which was debrided using a shaver. He 
also had some tearing of the bicep tendon and a tenotomy performed and his biceps stump was debrided using 
the shaver. He had a full-thickness tear of the supraspinatus which was partially debrided from the articular 
side. Therefore, the records do support that CPT 29823 was rendered. The operative note details cite from the 
anterior portal, a 10mm resection of the distal clavicle was performed using the burr. Therefore, the records do 
support that CPT 29824 was rendered in this case. Regarding the "full thickness tear of the supraspinatus", the 
operative note details cite an Iconix suture anchor was placed from an accessory lateral portal at the articular 
margin. Suture limbs were then passed from anterior to posterior in mattress fashion. They were then placed in 
an Omega knotless suture anchor after placing a Rotium patch over the sutures. The anchor was then fully seated and tension was applied to the sutures. Suture limbs were then cut. The repair was visualized in the 
posterior and lateral portals were found to be excellent. Therefore, the records do support that CPT 29827 was 
rendered in this case. The operative note details cite a small incision was then made over the pectoralis major. 
Incision was made through the skin down to the subcutaneous tissue. The biceps tendon was then pulled 
through the wound. The Iconix suture anchor was then placed in the bicipital groove and the sutures were 
whipstitched through the tendon. Excess tendon length was cut and the tendon was then tied down by hand, 
resulting in an excellent tenodesis. Therefore, the records do support that CPT 23430 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 services (procedure codes 23430, 29823, 29824, 29827) provided to the enrollee on May 20, 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.