Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 28234 and 28310 rendered on March 9, 2023. 
 
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 records do not support the services billed. 
 
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 28234: 
 
Tenotomy, open, extensor, foot or toe, each tendon 
 
CPT 28310: 
 
Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure) 
 
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 that the documentation supports both 
codes as separate and distinct procedures from CPT 28297 - correction, hallux valgus (bunionectomy), with 
sesamoidectomy. 
 
In terms of CPT 28234, The procedure details cite through the medial proximal phalanx incision, extensor 
hallucis longus scar tissue was released, the extensor hallucis longus was lengthened using a hemisection 
technique. Next the MPJ (metatarsophalangeal joint) was released with a dorsal capsulotomy. Therefore, the 
records support this code as a separate and distinct procedure. 
 
In terms of CPT 28310, a direct medial incision was created at the base of the proximal phalanx and a medially 
based wedge osteotomy was performed at the base of the proximal phalanx. A green stick fracture was created 
to close the wedge down. Hallux rested in the rectus position in the transverse plane and was fixated. The 
hallux was dorsally subluxed dorsally but reducible. Due to the previous surgery, there was an abundant scar 
tissue dorsally along the extensor hallucis tendon and MPJ (metatarsophalangeal joint). Through the medial 
proximal phalanx incision, extensor hallucis longus scar tissue was released, the extensor hallucis longus was 
lengthened using a hemisection technique. Next the MPJ was released with a dorsal capsulotomy. This allowed 
the hallux to be in a rectus position. The procedure details cite through the medial proximal phalanx incision, extensor hallucis longus scar tissue was released, the extensor hallucis longus was lengthened using a 
hemisection technique. Next the MPJ (metatarsophalangeal joint) was released with a dorsal capsulotomy. 
Therefore, the records support this code as separate and distinct. 
 
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 
procedure codes 28234 and 28310 rendered on March 9, 2023.  
 
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.