Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for CPT 63042 and 63044. We decided that the Plan does not have to pay 
for CPT 20936 and 69990.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that the records 
do not support the services billed. 
 
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 63042: 
 
Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, 
foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar 
 
CPT 63044: 
 
Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, 
foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional 
lumbar interspace (List separately in addition to code for primary procedure) 
 
CPT 69990: 
 
Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for 
primary procedure) 
 
We decided that the Plan has to pay for CPT 63042 and 63044.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 these codes. Our reviewer says that the medical 
records support CPT 63042 and 63044 in this case. This reviewer says that the description of the operation cites 
the central laminectomy occurred from L3 to S1 after mobilizing the dural edges. At this point, 2 PONTE 
osteotomies were done at L3-4 and L4-5 to allow for mobilization and complete freeing up of the neural 
elements, which allowed for correction in both the sagittal and coronal planes. Therefore, the records do 
support that CPT 63042 and 63044 were rendered in this case. 
 
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 
63042 and 63044.  
 
We also decided that the Plan does not have to pay for CPT 20936 and 69990. 
 
 
 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, we have confirmed that code 69990 
is a column II code to column I code 63042 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met.  
 
Additionally, 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 this code have not been met. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of 20936 and 69990 have not been met. Therefore, we decided that the Plan does not have to pay for 
20936 and 69990. 
 
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.