Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure code 22830, 22852, 63012, 76000) 
provided to the enrollee on April 12, 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 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 22830: 
 
Exploration of spinal fusion 
 
CPT 22852: 
 
Removal of posterior segmental instrumentation 
 
CPT 63012: 
 
Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda 
equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) 
 
CPT 76000: 
 
Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time 
 
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 records do support that CPT 
22830 was a separate and distinct procedure from CPT 22633. The description of the procedure cites 
fluoroscopic images were taken to confirm the levels and exploration of the fusion was carried out. This was 
performed prior to the arthrodesis procedure.  
 
In terms of CPT 22852, the records do support that it was a separate and distinct procedure from CPT 22842. 
The description of the procedure cites prior instrumentation was removed. This was after the fluoroscopic 
images were taken and exploration of the fusion was carried out. This again was performed prior to the 
posterior segmental instrumentation procedure.  
 
In terms of CPT 63012, the records do support it as a separate and distinct procedure from CPT 22633. The 
description of the procedure cites that at the L5-S1 level, a Gill-type decompression was done. Redo-type procedures, including resection of perineural fibrosis and exploration of neural elements were done from L4-5. 
All bone was removed using the Horsley bone cutter, Leksell rongeurs, various-sized Kerrison rongeurs and the 
high-speed pneumatic drill. This bone was morselized and saved for later use. This was performed prior to the 
arthrodesis procedure. 
 
Finally, for CPT 76000, the records do support that it was a separate and distinct procedure from CPT 22842. 
The description of the procedure cites fluoroscopic images taken to confirm the levels and exploration of the 
fusion was carried out. The fluoroscopic images were performed prior to the posterior segmental 
instrumentation took place. 
 
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 (procedure code 22830, 22852, 63012, 76000) provided to the enrollee on April 12, 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.