Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 63042. We decided that the Plan does not have to pay 
for procedure codes 63047 and 63048.  
 
You asked the Plan to pay for procedure codes 63047, 63042, and 63048 provided on September 26, 2022.. 
You say that the medical records support the billing of codes 63047, 63042, and 63048. The Plan says that the 
medical records do not support the billing of codes 63047, 63042, and 63048. 
 
We decided that the Plan has to pay for procedure code 63042.  
 
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 63042 is Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial 
facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; 
lumbar. 
 
We asked our physician reviewer 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 code 63042. Our reviewer says 
that the medical records support the billing of code 63042. Our physician reviewer found medical records do 
support the use of procedure code 63042 as the operation report does capture the excision of the herniated 
disks.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 63042 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 63042.  
 
We also decided that the Plan does not have to pay for procedure codes 63047 and 63048. 
 
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 63047 is Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of 
spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; 
lumbar. The definition of code 63048 is Laminectomy, facetectomy and foraminotomy (unilateral or bilateral 
with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), 
single vertebral segment; each additional vertebral segment, cervical, thoracic, or lumbar (List separately in 
addition to code for primary procedure). 
 
We asked our physician reviewer 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 63047 and 63048. Our 
reviewer says that the medical records do not support the use of procedure code 63047 as there is a more 
appropriate procedure code that can be used to capture the highest specificity. The medical records also do not 
support the use of procedure code 63048 as there is a more appropriate procedure code that can be used to 
capture the procedure as it was described and that would be more suitable to be billed with 63042. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 63047 and 63048 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 63047 and 63048. 
 
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.