Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services provided to the enrollee on April 26, 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 that these codes were denied as not supported in the medical records submitted. 
 
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 22554: 
 
Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for 
decompression); cervical below C2 
 
CPT 22585: 
 
Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for 
decompression); each additional interspace (List separately in addition to code for primary procedure) 
 
CPT 63081: 
 
Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of 
spinal cord and/or nerve root(s); cervical, single segment 
 
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 supported by the medical records. Our reviewer found that the enrollee was being treated for 
spondylosis with myelopathy of the cervical region and spinal stenosis of the cervical region. She underwent an 
anterior cervical discectomy and fusion with anterior instrumentation at C3-4, C4-5, and C5-6; anterior cervical 
discectomy with partial corpectomy and fusion at C6-7; anterior plate with instrumentation from C4-C7; 
anterior cervical arthrodesis with allograft C3-C7; use of neuromonitoring; use and interpretation of 
fluoroscopy on 4/26/22. The detailed operative description noted the discectomy was initiated with a #11 blade 
scalpel by incising the annulus. Discectomy was carried out utilizing pituitary rongeurs, Kerrison rongeurs, and 
curettes to widen and remove the anterior spur and disc complex in addition to remaining disc fragments. 
Discectomy was carried down to the level of the posterior longitudinal ligament. The interbody cages were 
packed and anchored in place at the C3-4, C4-5, C5-6, and C6-7 levels. Therefore, the records do support that 
CPT 22554 and CPT 22585 were rendered in this case. Additionally, the detailed operative description noted at 
C6-7 there was a partial corpectomy that was performed in order to decompress the spinal cord due to complete 
ossification of the disc space. The partial corpectomy was performed with a high-speed drill. Therefore, the 
records do support that CPT 63081 was rendered in this case. 
 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 been met. Therefore, we decided that the Plan has to pay for 
surgical services provided to the enrollee on April 26, 2022.  
 
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.