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 March 23, 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 support that the denied 
codes were rendered in this case. In terms of CPT 22830, the procedure details cite an exploration of the fusion 
was carried out and there appeared to be solid intervertebral arthrodesis without overt signs of failure or motion 
noted intraoperatively. 
 
In terms of CPT 22852, the procedure details cite prior instrumentation was removed. 
 
In terms of CPT 63012, the procedure details cite decompressive laminectomies/laminotomies with mesial 
facetectomies were done from L2 to S1. At the L3-4 level, a Gill-type decompression was done. Redo-type 
procedures, including resection of perineural fibrosis and exploration of neural elements were done from L4 to 
S1. All bone was removed using the Horsley bone cutter, Leksell rongeurs, various-sized Kerrison rongeurs, 
and high-speed pneumatic drill.  
In terms of CPT 76000, that the procedure details cite that fluoroscopic images were taken to confirm the 
levels. Also, fluoroscopic images were taken in anteroposterior and lateral planes to confirm appropriate 
placement of the instrumentation. Therefore, the records support all of the denied codes.  
 
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 March 23, 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.