Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 20680. We decided that the Plan does not have to pay for 28122 and 
28124.  
 
You asked the Plan to pay for surgical services (procedure codes 20680, 28122, 28124) provided to the enrollee 
on April 15, 2022. You say that this should be paid for. The Plan says that the records do not support the 
services billed. 
 
We decided that the Plan has to pay for 20680.  
 
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 
CPT 20680 is "Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)." 
 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 for CPT 20680. Our physician reviewer found that the 
records do support that CPT 20680: removal of implant, deep (e.g., buried wire, pin, screw, metal band, nail, 
rod, or plate) was rendered in this case. The procedure description noted a deep incision along the periosteal 
tissues was placed and a Key elevator was used to reflect the periosteal tissues, thus exposing the prominent 
screw in the 1st metatarsal. The screw was removed. Additionally, a Key elevator was then used to expose the 
prominent metallic implant on the proximal phalanx bone. The implant was removed. 
 
We looked at this physician'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 
20680.  
 
We also decided that the Plan does not have to pay for 28122 and 28124. 
 
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 remainder of the denied codes is: 
 
CPT 28122: 
 
Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or 
bossing); tarsal or metatarsal bone, except talus or calcaneus 
 
CPT 28124: 
 
Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or 
bossing); phalanx of toe 
 
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 for CPT 28122 and CPT 28124. Our physician 
reviewer found that the records do not support that either of these codes were rendered in this case. The 
procedure detailed fluoroscopic identification of hypertrophic bone was made at the midshaft of the 1st 
metatarsal and as such, the incision was extended to include this portion of the bone. The incision was 
deepened in the same surgical plane. Blunt dissection technique using a Metzenbaum scissors and a Key 
elevator was used to reflect the overlying soft tissues and the underlying hypertrophic bone spur was brought 
into the surgical field. A bone rasp was used to reduce the prominence of bone noted at the location flush with 
the remaining cortical metatarsal tissue. The procedure detailed a rongeur was used distally to remove the 
hypertrophic bone spurring of the proximal phalanx. The remaining base of bone was rasped smooth and 
flushed. However, the documentation does not corroborate cauterization, saucerization, sequestrectomy, or 
diaphysectomy being utilized. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 28122 and 28124 have not been met. Therefore, we decided that the Plan does 
not have to pay for 28122 and 28124. 
 
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.