Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services. We decided that the Plan does not have to pay for 29826.  
 
You asked the Plan to pay for the services. 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 29823.  
 
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])." 
 
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 29823. Our reviewer says that this code is 
supported in the submitted medical records. Our physician reviewer found that the enrollee was being treated 
for a complete rotator cuff tear or rupture of the right shoulder. He underwent right shoulder arthroscopic 
surgery on 5/24/21. The documentation is evident that (during the 5/24/21 procedure) 3 or more discrete 
structures were debrided. This included the partial cuff tear, SLAP lesion and bursa/bursectomy in 
combination. Therefore, CPT 29823 is/was supported. 
 
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 
29823.  
 
We also decided that the Plan does not have to pay for 29826. 
 
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 29826 is "Arthroscopy, shoulder, surgical; 
decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) 
release, when performed (List separately in addition to code for primary 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 29826. Our reviewer says that the 
documentation supports that the resection of the anterior lateral osteophyte of the acromion and 1.5cm of the 
distal clavicle were done. However, the use of CPT code 29826 is not appropriate (as this code would be 
inclusive to the CPT code 23412-51-RT.) Therefore, the records do not support that 29826 was applicable 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 29826 have not been met. Therefore, we decided that the Plan does not have to 
pay for 29826. 
 
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.