Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for laminectomy, facetectomy and foraminotomy (unilateral or bilateral 
with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), 
single vertebral segment; each additional vertebral segment, cervical, thoracic, or lumbar (List separately in 
addition to code for primary procedure) rendered on November 28, 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 
code 63048 is "Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of 
spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; 
each additional vertebral segment, cervical, thoracic, or lumbar (List separately in addition to code for primary 
procedure)." 
 
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 
spinal stenosis of the lumbar region with neurogenic claudication, intervertebral disc displacement of the 
lumbar region, spondylosis without myelopathy or radiculopathy of the lumbar region, and radiculopathy of the 
lumbar region. The enrollee underwent L4-5 laminotomy and bilateral foraminotomy and L5-S1 laminotomy 
via a right-sided approach, on 11/28/22. The procedure details cite a very hypertrophic facet and yellow 
ligament (that was removed in piecemeal fashion bilaterally at L4-5 and L5-S1.). There was severe 
compression dorsally and lateral to the traversing nerve root, as well as to the central portion of the thecal sac. 
The central decompression was carried out due to the significant amount of hypertrophic yellow ligament that 
was removed. Then, the traversing nerve root was skeletonized using a combination of Kerrrison punches used 
to decompression the foramen. Therefore, the records do support that CPT 63048 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 
laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda 
equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional 
vertebral segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) 
rendered on November 28, 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.