Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure codes 63012, 63056, 63057, 76000) 
rendered on June 13, 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 denied codes are not supported in the records submitted. 
 
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 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 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) 
 
CPT 63057: 
 
Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated 
intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to 
code for primary 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 procedure description cites 
decompressive laminectomies/laminotomies with mesial facetectomies were done from L2 to L5. At the L4-5 
level, a Gill-type decompression was done. All bone was removed using Horsely bone cutter, Leksell rongeurs, 
various sized Kerrison rongeurs, and the high-speed pneumatic drill. This bone was morselized and saved for 
later use. Therefore, the records do support that 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) was rendered in this case. In terms of CPT 63056, the procedure description cites at the 
L4-5 level a Gill-type decompression was done. All bone was removed using Horsely bone cutter, Leksell rongeurs, various sized Kerrison rongeurs, and the high-speed pneumatic drill. Therefore, the records support 
this code. In terms of CPT 63057, the procedure description cites decompressive laminectomies/laminotomies 
with mesial facetectomies were done from L2 to L5. At the L4-5 level, a Gill-type decompression was done. 
All bone was removed using Horsely bone cutter, Leksell rongeurs, various sized Kerrison rongeurs, and the 
high-speed pneumatic drill. Therefore, the records support this code. Finally, in terms of CPT 76000, the 
procedure description cites fluoroscopic images were taken in anteroposterior (AP) and lateral planes to 
confirm appropriate placement of instrumentation. The records therefore support this code. 
 
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 codes 63012, 63056, 63057, 76000) rendered on June 13, 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.