Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930, 20936, 22830, 22854, 63081, and 
63082 billed for date of service August 9, 2021. 
 
You asked the Plan to pay for procedure codes 20930, 20936, 22830, 22854, 63081, and 63082. You say that 
you have provided medical records to support payment of these codes. The Plan denied your request. The Plan 
says 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 definitions of the codes at issue are as follows:  For code 20930: Allograft, 
morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code 
for primary procedure); for code 20936: Autograft for spine surgery only (includes harvesting the graft); local 
(eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure); For code  22830: Exploration of spinal fusion; For code 22854:Insertion of 
intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for 
device anchoring (e.g, 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); For code 63081: Vertebral corpectomy (vertebral body 
resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); 
cervical, single segment; and For code 63082: Vertebral 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 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 procedure codes 20930, 20936, 22830, 22854, 63081, and 
63082. Our reviewer says that these codes are not supported in the medical record. Our reviewer found for 
codes 20930 and 20936, these have a Status Indicator of B, which indicates a service that's always bundled into 
another service. Reimbursement of this service is always included in the payment for another service, whether 
the code is billed on the same date of service as a primary code or billed alone on a different date or claim. For 
code 22830, the exploration of spinal fusion in this case would be inclusive to the primary procedure code and 
would not be reported separately. For code 63081, the operative report describes a vertebral corpectomy, with 
decompression of spinal cord and nerve roots, however, documentation is insufficient to verify one-half 
vertebral body removed for this segment. For code 63082, the operative report describes a vertebral 
corpectomy, with decompression of spinal cord and nerve roots, however, documentation is insufficient to 
verify one-half vertebral body removed for this segment.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 20930, 20936, 22830, 22854, 63081, and 63082 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 20930, 20936, 22830, 
22854, 63081, and 63082 billed for date of service August 9, 2021.