Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (63081, 63082, and 22854) provided on 
April 14, 2021. 
 
You asked the Plan to pay for codes 63081, 63082, and 22854. You say that the medical records support the 
billing of codes 63081, 63082, and 22854 provided on April 14, 2021. The Plan denied your request. The Plan 
says the medical records do not support the billing of codes 63081, 63082, and 22854 provided on April 14, 
2021. 
 
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 63081 is Vertebral corpectomy (vertebral body 
resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); 
cervical, single segment. The definition of code 63082 is Vertebral corpectomy (vertebral body resection), 
partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each 
additional segment (List separately in addition to code for primary procedure). The definition of code 22854 is Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior 
instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) 
(vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each 
contiguous defect (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 codes 63081, 63082, and 22854. Our reviewer says that the 
medical records do not support the billing of codes 63081, 63082, and 22854 provided on April 14, 2021. Our 
reviewer found based on the documentation submitted the billing of code 63081 is not supported. The operative 
report does not document how much vertebral body was removed to support reporting a corpectomy code. Per 
CPT guidelines "For vertebral corpectomy, the term partial is used to describe removal of a substantial portion 
of the body of the vertebra. In the cervical spine, the amount of bone removed is defined as at least one-half of 
the vertebral body. In the thoracic and lumbar spine, the amount of bone removed is defined as at least one-
third of the vertebral body". 
 
Based on the documentation submitted the billing of code 63082 is not supported. The operative report does 
not document how much vertebral body was removed to support reporting a corpectomy code. Per CPT 
guidelines "For vertebral corpectomy, the term partial is used to describe removal of a substantial portion of the 
body of the vertebra. In the cervical spine, the amount of bone removed is defined as at least one-half of the 
vertebral body. In the thoracic and lumbar spine, the amount of bone removed is defined as at least one-third of 
the vertebral body". 
 
Based on the documentation submitted the billing of code 22854 is not supported. The operative report does 
not clearly document a corpectomy, and therefore, a corpectomy cage cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 63081, 63082, and 22854 have not been met. Therefore, we decided that 
the Plan does not have to pay for the surgical services (63081, 63082, and 22854) provided on April 14, 2021.