Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 29898. We decided that the Plan does not have to pay for 27658, 
27680, and 27698.  
 
You asked the Plan to pay for procedure codes 27658, 27680, 27698, and 29898 provided to the enrollee on 
January 28, 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 29898.  
 
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 29898 is "Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, extensive." 
 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 29898. Our reviewer says that the procedure 
description cites arthritic changes were noted during arthroscopy on the distal talus as well as along the medial 
malleolus and lateral malleolus. There was evidence of hypertrophic impingement and synovitis noted 
throughout the ankle. The synovitis was debrided throughout the ankle joint with a shaver. Therefore, the 
records do support that CPT 29898: arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, 
extensive was rendered in this case. 
 
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 
29898.  
 
We also decided that the Plan does not have to pay for 27658, 27680, and 27698. 
 
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 27658: 
 
Repair, flexor tendon, leg; primary, without graft, each tendon 
 
CPT 27680: 
 
Tenolysis, flexor or extensor tendon, leg and/or ankle; single, each tendon 
 
CPT 27698: 
 
Repair, secondary, disrupted ligament, ankle, collateral (eg, Watson-Jones 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 for CPT 27658, CPT 27680 and CPT 27698. Our 
reviewer says that the procedure description does not document that there was a repair of the flexor tendon. 
There was a radiofrequency procedure to promote "rejuvenation and increasing blood flow " to the right tibialis 
posterior tendon and peroneal tendon. However, the records do not support that CPT 27658 was rendered in 
this case. 
 
Additionally, in terms of CPT 27680, the procedure description does not document that there was a tenolysis, 
flexor or extensor tendon. There was a radiofrequency procedure to promote "rejuvenation aand increasing 
blood flow " to the right tibialis posterior tendon and peroneal tendon. Therefore, the records do not support 
that this code was rendered in this case. 
 
Finally, in terms of CPT 27698, the procedure description does not document that there was a repair, 
secondary, disrupted ligament. There was a synovial debridement, and radiofrequency procedure at multiple 
structures. Therefore, the records do not support that records do not support that CPT 27698 was rendered in 
this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 27658, 27680, and 27698 have not been met. Therefore, we decided that the 
Plan does not have to pay for 27658, 27680, and 27698. 
 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.