Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 29822. We decided that the Plan does not have to pay for 29826.  
 
You asked the Plan to pay for procedure code 29822 and 29826 rendered on June 15, 2023. You say that this 
should be paid for. The Plan says that the denied code remains not supported. 
 
We decided that the Plan has to pay for 29822.  
 
The Plan follows Medicare rules. Medicare rules say that services must be reported correctly. The definition of 
CPT 29822 is "Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 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 29822. Our reviewer says that that the 
procedure details cite debridement was performed on the subscapularis tendon, which had some frayed and 
hypertrophy synovial tissues. There was also some frayed tissue off of the rotator cuff which was removed with 
the shaver. Then a different shaver (electroblade) was utilized to remove this additional bony prominence 
(recurrence of spurring off the distal clavicle) which seemed to be causing some impingement. Therefore, the 
documentation does support CPT 29822 as a separate and distinct procedure from CPT 29824. 
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for 29822.  
 
We also decided that the Plan does not have to pay for 29826. 
 
The Plan follows Medicare rules. Medicare rules say that services must be reported correctly. The definition of 
CPT 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 CPT 29805 
would not typically be supported as a separate and distinct procedure as it would be considered global under 
the primary 29826. 
 
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 item/service at issue 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.