Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for 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 (CPT code 63047-62-58-XS) and 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 segment, cervical, thoracic, or
lumbar (CPT code 63048-62 X 5) provided to the enrollee on May 5, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says the services are not supported by the records.
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 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 found the review has determined
that Procedure code 63047-62-58-XS is not supported by the medical records submitted. The operative report
did not include documentation of a laminectomy, facetectomy and foraminotomy (unilateral or bilateral with
decompression of spinal cord, cauda equina and/or nerve root[s], [spinal or lateral recess stenosis]), for a single
lumbar vertebral segment; therefore, this code cannot be verified. After careful review of the operative report,
the Medical Director states; "the requested service code is not substantiated by the clinical documentation in
the medical records submitted for review. To cite the operative report; "Next, the pedicle screws were placed
from T10-S1. Pedicle entrance point was identified into transverse process and facet junction. We decorticated
the pedicle entrance point. Gearshift probe introduced from pedicle entrance point down to the pedicle and
vertebral body. We remove the posterior elements from T11-S1. Osteotomy performed specifically by
removing each inferior facet joints with osteotome, which allow further mobilization. Next TLIF performed at
L4-5 in usual fashion removing facets and performing wide laminectomy L4-5 on right side. Disc removed and
end plates prepared. Cage filled with allograft and impacted into position at L4-5 and position checked with x-
ray. Accessory rods were placed for four rod construct from additional pelvic fixation proximally to
thoracolumbar junction. The wound was then closed in layers over drains after posterolateral fusion T10-S1
decortication and placement of the BMP, iliac crest bone graft and allograft."
In regards to the submitted (CPT) code of 63047-62-58-XS, the patient is face down.  Magnification may be
used during the procedure. The physician makes a midline incision overlying the affected vertebrae. Fascia is
incised. Paravertebral muscles are retracted. The physician removes the spinous processes with rongeurs. If the
stenosis is central, the physician removes the lamina out to the articular facets using a burr. If the compression
is in the lateral recess, only half of the lamina is removed. A Penfield elevator peels the ligamentum flavum
away from the dura. Nerve root canals are freed by additional resection of the facet, and compression is
relieved by removal of any bony or tissue overgrowth around the foramen. Removal of the lamina, facets, and
bony tissue or overgrowths may be performed bilaterally when indicated. The rongeur, retractor, and
microscope are removed. A free-fat graft may be placed over the nerve root(s) for protection. If the ligamentum
flavum was spared, it is placed over the free-fat graft. Paravertebral muscles are repositioned, and the deeper
tissues and skin are closed with layered sutures. Report 63046 if the procedure affects a thoracic vertebra;
report 63047 if the procedure affects a lumbar vertebra; and 63048 for procedures affecting each additional
vertebra. Report 63048 in addition to 63045-63047. Arthrodesis is reported separately, see 22590-22614.This
description was not documented in the operate report narrative. According to (CPT) code definitions and
guidance, this case involves an inappropriate billing of (CPT) code 63047-62-58-XS. (CPT) code 63047-62-58-
XS is not supported in the documentation therefore is not payable.
The review has determined that the services were not supported by the medical records provided.
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 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 (CPT code 63047-62-58-XS) and 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 segment, cervical, thoracic, or lumbar (CPT code 63048-62 X 5)
provided to the enrollee on May 5, 2021