Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure codes 20936, 61783, 63045, 
63048) provided to the enrollee on February 22, 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 the denied codes remain not supported. 
 
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 20936: 
 
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) 
 
 
 CPT 61783: 
 
Stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to code for primary 
procedure) 
 
CPT 63045: 
 
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; cervical 
 
CPT 63048: 
 
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 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 not supported by the medical records. Our reviewer found that in terms of CPT 20936, the 
operative report does not describe harvesting autograft and therefore this procedure cannot be verified. The 
operative report documents "Respectively with placement of autograft and bone substitute."  CPT 20936 
describes grafting from a donor area using the same incision during a major operative procedure. CPT 61783 is 
an "add-on" code for the primary procedure CPT 63045 which in this case cannot be verified.  Therefore this 
procedure would not be covered. In terms of CPT 63045, the operative report does not include documentation 
of a laminectomy, facetectomy, and forminotomy per CPT code description.  Operative report describes 
laminectomy performed, which there is another procedure code that should be reported for service provided. In 
terms of CPT 63048, this procedure is an "add-on" procedure for CPT 63045 which in this case cannot be 
verified as the operative report does not include documentation of a laminectomy, facetectomy, and 
forminotomy per CPT code description.  Therefore, additional vertebral segment cannot be verified. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure codes 20936, 61783, 63045, 63048) provided to the enrollee on 
February 22, 2022.