Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services provided to the enrollee on December 3, 2021. 
 
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 denied codes are not supported by the medical records submitted. 
 
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 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 29825: 
 
Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation 
 
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 the records do support that the codes 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]) and CPT 29825- arthroscopy, shoulder, surgical: with lysis and resection of adhesions with 
or without manipulation were rendered in this case. The procedure note does indicate that code 29823 was 
performed. The shaver was inserted into the joint to perform an extensive debridement to include debridement 
of degenerative fraying along the superior and inferior portions of the labrum, partial synovectomy, and 
debridement of the greater tuberosity footprint to bleeding cortical bone. Shaver was inserted to resect the 
pathologically thickened anterior capsule and rotator cuff interval tissue back to more normal healthy tissue 
margins. The procedure note also indicates that CPT 29825 was performed. Shaver was inserted to resect the 
pathologically thickened anterior capsule and rotator cuff interval tissue back to more normal healthy tissue 
margins. The arm was taken out of the holder and performed gradual progressive manipulation under 
anesthesia and was able to stretch the shoulder joint out to about 180 degrees forward flexion, 170 abduction, 
80 external rotation and 80 internal rotation. 
 
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 provided to the enrollee on December 3, 2021.   
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.