Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe insertion of intervertebral biomechanical device services coded 22854, the vertebral corpectomy services coded 63081, and the vertebral corpectomy services coded 63082 provided on May 31, 2019.You asked the Plan to pay forthe insertion of intervertebral biomechanical device services and the vertebral corpectomy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 22854 is Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure).The CPT Code Manual definition of code 63081 is vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segmentThe CPT Code Manual definition of code 63082 isvertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment (List separately in addition to code for primary procedure).We find that CPT codes 22854, 63081, 63082 are not supported in the medical record. Specifically, the medical records did not include documentation of an insertion of intervertebral biomechanical device(s) (synthetic cage, mesh), with integral anterior instrumentation for device anchoring (screws, flanges) when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, for each contiguous defect (listed separately in addition to code for primary procedure); therefore, code 22854 cannot be verified. The medical records did not include documentation of a partial or complete vertebral corpectomy (vertebral body resection), using an anterior approach with decompression of spinal cord and/or nerve root(s), for a single cervical segment; therefore, code 63081 cannot be verified. The medical records did not include documentation of a partial or complete vertebral corpectomy (vertebral body resection), using an anterior approach with decompression of spinal cord and/or nerve root(s), for each additional cervical segment (listed separately in addition to code for primary procedure); therefore, code 63082 cannot be verified.Based on this information, we decided that Medicare rules for coverage of the insertion of intervertebral biomechanical device services and the vertebral corpectomy services have not been met. Therefore, we decided that the Plan does not have to pay forthe insertion of intervertebral biomechanical device services coded 22854, the vertebral corpectomy services coded 63081, and the vertebral corpectomy services coded 63082 provided on May 31, 2019.