Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 22852. We decided that the Plan does not have to pay for 63012 and 
22830.  
 
You asked the Plan to pay for surgical services (procedure codes 22830, 22852, 63012) provided to the enrollee 
on January 11, 2022.. You say that this should be paid for. The Plan says that the denied codes cannot be 
verified. 
 
We decided that the Plan has to pay for 22852.  
 
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 CPT 22852 Our reviewer says that the operative 
narrative cites that the spinous processes were exposed from T12 to L5 including the prior surgical site and 
instrumentation. Fluoroscopic images were taken. The exploration of fusion was carried out. There appeared to 
be solid intervertebral arthrodesis without overt signs of failure or motion noted intraoperatively. Intervertebral 
cages were well placed. Next, prior instrumentation was removed. The removal of the hardware was separate 
from the spinal fusion procedure, as the previous instrumentation had to be removed prior to the fusion from 
T12 to L5. Therefore, the records do support CPT 22852: removal of posterior segmental instrumentation as a 
separate and distinct procedure from CPT 22842- posterior segmental instrumentation (e.g., pedicle fixation, 
dual rods with multiple hooks and sublaminar wires); 3-6 vertebral segments (list separately in addition to code 
for primary procedure). 
 
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 
22852.  
 
We also decided that the Plan does not have to pay for 63012 and 22830. 
 
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 CPT 63012 and 22830 Our reviewer says that in 
terms of CPT 63012, the operative narrative cites that during the lumbar fusion procedure itself, the 
decompressive laminectomies/laminotomies with mesial facetectomies were done from T12-L5. At the L4-5 
level, a Gill-type decompression was done. This was not a separate procedure but appears to a part of the more 
comprehensive fusion procedure. Therefore, the records do not support reporting CPT 63012 separately.  
 
In terms of CPT 22830, the operative narrative cites that the spinous processes were exposed from T12 to L5 
including the prior surgical site and instrumentation. Fluoroscopic images were taken. The exploration of 
fusion was carried out. There appeared to be solid intervertebral arthrodesis, without over signs of failure or 
motion noted intraoperatively. Intervertebral cages were well placed. Next, prior instrumentation was removed. 
The exploration was part of the more comprehensive spinal fusion procedure, as the previous instrumentation 
had to be explored and/or examined (prior to prior instrumentation removal) to allow for and ensure an 
indication for the fusion from T12 to L5. Therefore, the records do not support the use of CPT 22830 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 63012 and 22830 have not been met. Therefore, we decided that the Plan does 
not have to pay for 63012 and 22830. 
 
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.