Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 22554, 22585, 22845, 63081, and 63082 provided to 
the enrollee on September 1, 2022. 
 
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 22554: 
 
Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for 
decompression) 
 
CPT 22585: 
 
Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for 
decompression) 
 
CPT 22845: 
 
Anterior instrumentation; 2 to 3 vertebral segments 
 
CPT 63081: 
 
Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of 
spinal cord and/or nerve root(s) 
 
CPT 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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the records support that all of the 
codes were rendered in this case. In terms of CPT 22554, the procedure description cites the dissection was 
directed more at the vertebral body of C4 with removal of the interior one-half of the vertebral body of C5. The 
posterior region was decompressed, and measurements were obtained for bone grafting. Therefore, records do support CPT 22554 in this case. 
 
In terms of CPT 22585, the procedure details cite there was residual disc material which was removed. The 
inferior one-half of the vertebral body of C7 and superior one-half of vertebral body of T1 were then removed. 
The partial vertebrectomy allowed for position decompression followed by measurement for allograft 
placement. This was achieved again using 5mm height 14mm wide Cornerstone allograft. The central hole was 
packed with cortical cancellous autologous bone and the hybrid construct was stamped into place under 
compression at the C7-T1 level of partial vertebrectomy. Therefore, the records do support CPT 22585 in this 
case. 
 
In terms of CPT 22854, the procedure details cite this was a 5mm height, 14mm wide Cornerstone allograft and 
it was packed in the central hole with autologous bone graft harvested during the partial vertebrectomy portion 
of the procedure. This hybrid graft was stamped into place under compression and countersunk 2mm below the 
anterior surface of the spinal column. Therefore, the records do support CPT 22854 in this case. 
 
In terms of CPT 63081, the procedure details cite the dissection was directed more at the vertebral body of C4 
with removal of the interior one-half of the vertebral body of C5. Therefore, the records do support CPT 63081. 
 
Finally, in terms of CPT 63082, the procedure details cite attention was then directed at the C7-T1 level. There 
was residual disc material which was removed. The inferior one-half of the vertebral body of C7 and superior 
one-half of vertebral body of T1 were then removed. The partial vertebrectomy allowed for position 
decompression followed by measurement for allograft placement. Therefore, the records do support CPT 63082 
in this case. 
 
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 22554, 22585, 22845, 63081, and 63082 provided to the enrollee on September 1, 2022.  
 
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.