Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 20939 and 63056. We decided that the Plan does not have to pay for 
20937.  
 
You asked the Plan to pay for surgical services (procedure codes 20937, 20939, 63056) provided to the enrollee 
on September 9, 2022.. You say that this should be paid for. The Plan says that the records do not support the 
services billed. 
 
We decided that the Plan has to pay for 20939 and 63056.  
 
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 20939 and CPT 63056. The definition of these 
codes is: 
 
CPT 20939: 
 
Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (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) 
 
Our reviewer says that in terms of CPT 20939, the procedure details cite a Jamshidi needle placed in the upper 
right pedicle inside of the vertebral body and bone marrow has been aspirated to be mixed with biologics to 
introduce Stem cells to the biologics. This was performed through a separate skin puncture via needle/separate 
site. Therefore, the records do support that CPT 20939 was rendered in this case. Additionally, the records also 
support that CPT 63056. The enrollee was turned so that a near-direct anterior-lateral approach to the lumbar 
spine could be achieved. A small incision was made superior to the mid-iliac crest and then using biplanar 
fluoroscopic visualization, an electrophysiological probe was introduced through the retro peritoneal space into 
the desired discs anterior to the traverse processes and then passed into the disc space after finding a silent 
window. The sleeve is retained and the probe is removed. A K wire was passed sequentially into the disc space. 
A dilating tube was then passed along this same route. Following this, a working channel was then passed 
sequentially into the disc spaces. The working channel was manually held in position while a series of disc 
cleaning tools were pass through the channel to remove the affected discs under clear and direct biplanar 
fluoroscopic visualization, decompress the nerve roots, and decorticate the vertebral endplates at those 
segments. The "entry point" was via the pedicles. This corroborates the procedure being trans-pedicular.  
 
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 
20939 and 63056.  
 
We also decided that the Plan does not have to pay for 20937. 
 
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 20937. The definition of this code is 
"Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial 
incision) (List separately in addition to code for primary procedure)." Our reviewer says that the procedure 
details cite that a needle was used to aspirate bone marrow. After adequate decompression and preparation of 
the endplates, the calcium triphosphate was placed anterior to the disc space. The working channel was then 
removed after a K wire was reinserted. The interbody was packed tightly with allograft bone for stabilization 
and arthrodesis of the intervertebral spaces and inserted into the mid portion of the intervertebral discs. This 
was not performed through a separate skin or fascial incision. Therefore, the records do not support that CPT 
20937: autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or 
fascial incision) (List separately in addition to code for primary procedure)- was rendered 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 20937 have not been met. Therefore, we decided that the Plan does not have to 
pay for 20937. 
 
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.