Wiki Subacromial Decompression-29826

[bebelke]

I work in AR for an orthopedic practice, primarily with Anthem BCBS. We have to submit pre-authorizations to AIM specialty health, who refuses to authorize 29826 for subacromial impingement syndrome. They state it is never medically necessary for that diagnosis. The doctors are doing the bony work, removing part of the acromion, etc. Anthem will not approve my appeals because they say it is not medically necessary. Does anyone have any ideas on how to get this paid? Last I checked, 29826 was billable if bony work was done. Any help would be appreciated. I don't know where to go from here. Thanks

 

[JessicaPerdue]

I have been told in the past the provider has to do a peer to peer review to get this approved.

 

[Orthocoderpgu]

BX just recently made this policy switch. There is no reason for it other than internal as it is medically necessary and treats a specific condition that is not treated directly or indirectly with a RTC repair. The current president of AAOS has already contacted BX showing the negative patient outcomes. You can also get 29827 & 29824 denied as well, which again does not make any sense. In 2017 CMS finally allowed 29823 although under very restricted conditions. I thought that this would move forward shoulder coding, but it seems to have backfired. Rather than opening the door to paying for procedures that are separate and not bundled, now we seem to be regressing without any logic behind the decision making. I thought medical necessity was the over-arching criteria, guess not.