Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (22633, 27279, 22634, and 22853) 
provided on November 9, 2021. 
 
You asked the Plan to pay for procedure codes 22633, 27279, 22634, and 22853. You say that the medical 
records support the billing of codes 22633, 27279, 22634, and 22853. The Plan denied your request. The Plan 
says the medical records do not support the billing of codes 22633, 27279, 22634, and 22853. 
 
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 22633 is Arthrodesis, combined posterior or 
posterolateral technique with posterior interbody technique including laminectomy and/or discectomy 
sufficient to prepare interspace (other than for decompression), single interspace, lumbar. The definition of 
code 27279 is Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with 
image guidance, includes obtaining bone graft when performed, and placement of transfixing device. The 
definition of code 22634 is Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for 
decompression), single interspace, lumbar; each additional interspace (List separately in addition to code for 
primary procedure). The definition of code 22853 is Insertion of interbody biomechanical device(s) (eg, 
synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when 
performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (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 procedure codes 22633, 27279, 22634, and 22853. Our 
reviewer says that the medical records do not support the billing of codes 22633, 27279, 22634, and 22853. 
Our reviewer found the documentation submitted was reviewed, and the medical records do not support the 
billing of code 22633. The operative report does not describe (per NCCI Policy, "Physician makes an incision 
overlying the lumbar vertebrae and separates the fascia and the supraspinous ligaments in line with the incision. 
The physician prepares the vertebrae and lifts ligaments and muscles out of the way.  A chisel elevator is used 
to strip away the capsules of the lateral articulations and the articular cartilage and cortical bone are excised.  
Separately reportable chips are cut from the fossa below the lateral articulations and from the laminae, or 
fragments of the spinous process are taken for grafting.  Laminectomies and partial facetectomies are 
performed to facilitate preparation of the interspace for fusion") the procedure 22633 Arthrodesis, combined 
posterior or posterolateral technique with posterior interbody technique including laminectomy and/or 
discectomy sufficient to prepare interspace (other than for decompression), single interspace; lumbar. Unable to 
cite report as this procedure was not documented in operative report and cannot be verified. 
 
The documentation submitted was reviewed, and the medical records do not support the billing of code 27279. 
The operative report does not describe (per NCCI Policy, "A small incision is made through the gluteal fascia 
and muscle to reach the ilium.  Under fluoroscopic or CT guidance, a pin is placed from the ilium through the 
sacroiliac joint to the lateral portion of the sacrum.  A soft tissue protector is inserted over the pin, and a drill is 
used to create a pathway and decorticate bone through the ilium to the sacrum.  A depth gauge is used to 
determine implant length"). CPT 27279 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive 
(indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of 
transfixing device. Unable to cite report as this procedure was not documented in operative report and cannot 
be verified. 
 
The documentation submitted was reviewed, and the medical records do not support the billing of code 22634. 
The operative report does not describe (per NCCI Policy, "The physician makes an incision overlying the 
lumbar vertebrae and separates the fascia and the supraspinous ligaments in line with the incision.  The 
physician prepares the vertebrae and lifts ligaments and muscles out of the way.  A chisel elevator is used to 
strip away the capsules of the lateral articulations and the articular cartilage and cortical bone are excised"). 
CPT 22634 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique 
including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), 
single interspace, lumbar; each additional interspace.  Unable to cite report as this procedure was not 
documented in operative report and cannot be verified. 
 
CPT 22853- The documentation submitted was reviewed, and the medical records do not support the billing of 
code 22853. The operative report does not describe (per NCCI Policy, "a hole is cored out of the vertebral 
bodies above and below the removed vertebrae to secure a biomechanical device (synthetic cage or mesh) into 
the resulting intervertebral disc space.  The physician selects the biomechanical device best suited to the 
location and type of deformity being corrected.  Screws, wires, or plates may be used to secure the device.  
Muscles are allowed to fall back into place and the wound is closed over a drain with layered sutures").  CPT 
22853 Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior 
instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in 
conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary 
procedure).  Operative report documents "We used a 5.5 tap, we placed 8.5 x 50 mm screws bilaterally at the L2 pedicle...In a more intermittent unchanged position on the left-hand side, we used a percutaneous incision of 
the ___and cephalad screw in a convergent and parallel technique___.  We used a series of sequential dilators, 
used a 5.5 mm tap and a 7.5 mm tap, and placed a ___screws on the left-hand side... We rechecked our 
decompression pedicle to bone graft and this critical to the ___fashion in the screws as well as all cortical 
screws___".  In this case, CPT 22853 cannot be verified in the operative report. Of note, the operative report 
has many spaces in documentation, with missing words. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 22633, 27279, 22634, and 22853 have not been met. 
Therefore, we decided that the Plan does not have to pay for the surgical services (22633, 27279, 22634, and 
22853) provided on November 9, 2021.