Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the spine fracture treatment (22325 and 22328) and laminectomy (63267) provided on June 15, 2021.   You asked the Plan to pay for the spine fracture treatment (22325 and 22328) and laminectomy (63267). You say that you attached the Neurosurgery Coding Companion literature to support that CPT code 63267, 22325 and 22328 are separately payable when performed at a separate vertebral level. You say that the attached documentation should be reviewed, and payment should be released in a timely manner. The Plan denied your request. The Plan says the records do not support procedure codes 22325-AS-XS and 22328-AS-XS. The Plan also says that CPT code 63267 is inclusive to another billed code.  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 22325 is open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; lumbar. The CPT Code Manual definition of code 22328 is open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; each additional fractured vertebra or dislocated segment (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 63267 is laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar.  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 spine fracture treatment (22325 and 22328) and laminectomy (63267). Our reviewer says that this does not meet the criteria for billing or reimbursement consideration. Our reviewer found that the medical records provided do not include sufficient documentation to validate that CPT code 22325 was performed, therefore this procedure cannot be verified. Procedure code 22328 AS XS is an add-on code to CPT 22325 AS XS and is only eligible for reimbursement if 22325 AS XS is eligible for reimbursement. In this case, 22325 AS XS was not eligible for reimbursement, therefore 22328 AS XS is not eligible for reimbursement.  CPT code 63267 AS XS has a bundled relationship with CPT 22633 AS XS, however, the use of an appropriate modifier is allowed to unbundle this relationship, providing the medical records support the use of the modifier. In this case, the medical records do not include sufficient documentation to validate that 63267 AS XS was performed as a distinct, separate service, therefore the use of the modifier XS is inappropriate and no additional reimbursement is allowed.  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 spine fracture treatment (22325 and 22328) and laminectomy (63267) have not been met. Therefore, we decided that the Plan does not have to pay for the spine fracture treatment (22325 and 22328) and laminectomy (63267) provided on June 15, 2021.