Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for code 22854. We decided that the Plan does not have to pay for codes 63090 and 63091.
You asked the Plan to pay for codes 63090, 63091, and 22854. You say that the medical records support the billing of codes 22854, 63090, and 63091. The Plan says that the medical records do not support the billing of codes 22854, 63090, and 63091.
We decided that the Plan has to pay for code 22854.
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 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 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 to pay for code 22854. Our reviewer says that the medical records support the billing of code 22854. The Operative Report documents the Insertion of an intervertebral biomechanical device 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. Code 22854 is supported. The Operative Report documents that the interbody space was sized and a 13 mm 8 degree large footprint Spira synthetic interbody device was selected as the appropriate implant to restore inner disc space height and lordosis and spinal alignment. Local autograft and allograft were then packed inside the interbody device and inserted into the interspace without difficulty. Anterior plate instrumentation was then fashioned spanning L5 and S1. Screws were drilled, measured, and inserted into L5 and S1. The screws were tightened securely and locked to the manufacture's specifications. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 22854 have been met. Therefore, we decided that the Plan has to pay for code 22854.
We also decided that the Plan does not have to pay for codes 63090 and 63091.
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 63090 is Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment. The definition of code 63091 is Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment (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 to pay for codes 63090 and 63091. Our reviewer says that the medical records do not support the billing of codes 63090 and 63091. Our physician reviewer found the Operative Report does not include documentation of vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment. Code 63090 is not supported. The Operative Report does not include documentation of vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment (List separately in addition to code for primary procedure). Code 63091 is not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 63090 and 63091 have not been met. Therefore, we decided that the Plan does not have to pay for codes 63090 and 63091.
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.