Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services. We decided that the Plan does not have to pay for 63047 
and 63048.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that the denied 
codes are not supported by the medical records. 
 
We decided that the Plan has to pay for 20936.  
 
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 
CPT 20936 is "Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, 
or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure)." 
 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 this code. Our reviewer says that CPT 20936 was 
supported by the medical records. Our physician reviewer found that the documentation was reviewed and, to 
cite the operative report "All bone was put aside and morselized for later use"; "We impacted an 8 mm lordotic 
PEEK cage packed with local bone. We sequentially then did the L4-5 level in the same manner and at this 
level we placed an 11 mm lordotic PEEK cage packed with local bone, and at L3-4 level in the same manner 
we placed a 10 mm lordotic PEEK cage packed with local bone." The operative report describes bone taken 
from incision. 
 
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 
20936.  
 
We also decided that the Plan does not have to pay for 63047 and 63048. 
 
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 63047: 
 
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; lumbar 
 
CPT 63048: 
 
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 
segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) 
 
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 these codes. Our reviewer says that the records do 
not support these denied codes. Our physician reviewer found that CPT 63047 was unbundled from CPT 
22633, and CPT 63048 was unbundled from CPT 22634. Both of these procedures include a laminectomy. 
Another laminectomy at a different site was not documented. Therefore, these codes would not be reported 
separately. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 63047 and 63048 have not been met. Therefore, we decided that the Plan does 
not have to pay for 63047 and 63048. 
 
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.