Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on November 30, 
2021. 
 
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 records do not support the services billed. 
 
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 22614: 
 
Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral 
segment (List separately in addition to primary procedure) 
 
CPT 22634: 
 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; each additional interspace (List separately in addition to code for primary procedure) 
 
CPT 22842: 
 
Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 
3 to 6 vertebral segments (List separately in addition to code for primary procedure) 
 
CPT 22843: 
 
Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation 
for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with 
interbody arthrodesis, each interspace (List separately in addition to code for primary procedure) 
 
CPT 63056: 
 
Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated 
intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far 
lateral herniated intervertebral disc) 
 
CPT 63057: 
 
Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated 
intervertebral disc), single segment; each additional segment, 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 these denied codes were billed 
modifier 22. In this case, ZZZ = Code is related to another service and always included in the global period of 
another service. The procedure/service is usually an add-on code and is always bundled into the primary 
service, operative report does not include documentation per Medicare for increased procedural services were 
performed. Modifier 22 means unusual procedural services. This modifier indicates that a procedure was 
complicated, complex, difficult, or took significantly more time than usually required by the provider to 
complete the procedure. The documentation should be in simple "layman technology" and contained in the 
operative report. The operative report should be attached to the claim. 
 
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 provided to the enrollee on November 30, 2021.