Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 76000. We decided that the Plan does not have to pay for 20936.  
 You asked the Plan to pay for fluoroscopy and autograft services (procedure codes 76000 and 20936) provided 
to the enrollee on May 6, 2021. You say that this should be paid for. The Plan says that the denied codes 
remain not supported. 
 
We decided that the Plan has to pay for 76000.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 76000 is "Fluoroscopy 
(separate procedure), up to 1 hour physician or other qualified health care professional time." 
 
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 for CPT 76000. Our reviewer says that the records do 
support that CPT 76000 was a separate and distinct procedure from CPT 22633- arthrodesis, combined 
posterior or posterolateral technique with posterior interbody technique including laminectomy and/or 
discectomy sufficient to prepare interspace (other than for decompression), single interspace, lumbar. The 
enrollee was being treated for spinal stenosis of the lumbar region with neurogenic claudication; 
spondylolisthesis; spondylosis without myelopathy or radiculopathy of the lumbar region. He underwent L4-5 
and L5-S1 laminectomy, foraminotomy, medial facetectomy, discectomy, pars osteotomy, transforaminal 
lumbar interbody fusion/instrumented spinal fusion, allograft, autograft, bone marrow aspirate, osteoamp, and 
cell saver on 5/6/21. The procedure notes corroborate that after the procedure was completed and the suture 
was closed, imaging was performed which revealed the proper area was operated on and that the hardware was 
in good position. 
 
We looked at this physician'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 
76000.  
 
We also decided that the Plan does not have to pay for 20936. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 20936 is "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)." 
 
We find that procedure code 20936 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20936 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of 20936 have not been met. Therefore, we decided that the Plan does not have to pay for 20936. 
 
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.