Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services provided to the enrollee on October 25, 2021. 
 
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 21600: 
 
Excision of rib, partial 
 
CPT 63090: 
 
Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal 
approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; 
single segment 
 
CPT 63091: 
 
Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal 
approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; 
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 that the records do 
support that the denied codes were rendered in this case. Our reviewer found that the enrollee was being treated 
for other intervertebral disc degeneration of the lumbar region; spinal stenosis of the lumbar region with 
neurogenic claudication; and spondylolisthesis of the lumbar region.  He underwent a partial corpectomy of L1, 
L2, and L3; L1-3 arthrodesis with SeaSpine waveform titanium interbody cage with local morselized autograft 
and osteocurrent synthetic arthrodesis; insertion of titanium cages at 2 separate levels; L1-2 and L2-3 lateral 
Regatta plating systems with biocritical screws on 10/25/21. In terms of CPT 21600, the description of the 
procedure notes an incision was made over the body of L2. A small portion of the traversing rib was removed 
and the left retroperitoneal space was entered. For CPT 63090, the disc at L1-2 and L2-3 was incised, removed 
the disc from the endplates. Box cutter was used to shave off the disc and distractors were used. Disc spaces 
were quite arthrodesed and collapsed down. Hence, partial corpectomy of L1, L2, and L3 were completed in a 
standard fashion. In terms of CPT 63091, the disc at L1-2 and L2-3 was incised, removed the disc from the 
endplates. Box cutter was used to shave off the disc and distractors were used. Disc spaces were quite 
arthrodesed and collapsed down. Hence, partial corpectomy of L1, L2, and L3 were completed in a standard 
fashion. The denied codes were supported in the records.  
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 
surgical services provided to the enrollee on October 25, 2021.  
 
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.