Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 63056 and 63057. We decided that the Plan does not have to pay for 
22214, 22216, 63102 and 63103.  
 
You asked the Plan to pay for surgical services (procedure codes 22214, 22216, 63056, 63057, 63102, and 
63103) provided to the enrollee on June 20, 2022.. You say that this should be paid for. The Plan says that the 
records do not support the services billed. 
 
The definition of the denied codes is: 
 
CPT 22214: 
 
Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar 
 CPT 22216: 
 
Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral 
segment (List separately in addition to primary 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 63102: 
 
Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with 
decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); lumbar, single 
segment 
 
CPT 63103: 
 
Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with 
decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic or 
lumbar, each additional segment (List separately in addition to code for primary procedure) 
 
We decided that the Plan has to pay for 63056 and 63057.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 CPT 63056 and CPT 63057. Our reviewer says that 
the records support that the procedure details cite lateral recess decompression, partial transpedicular 
approaches were implemented and developed from L2-5 and for ventral-ventral and ventral-lateral 
decompression of the thecal sac partial posterior extra-cavitary approaches were implemented and developed 
using the instruments as well. Therefore, the records do support that CPT 63056 and CPT 63057 were rendered 
in this case. The procedure details cite lateral recess decompression, partial transpedicular approaches were 
implemented and developed from L2-5 and for ventral-ventral and ventral-lateral decompression of the thecal 
sac partial posterior extra-cavitary approaches were implemented and developed using the instruments as well. 
 
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 
63056 and 63057.  
 
We also decided that the Plan does not have to pay for 22214, 22216, 63102 and 63103. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
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 CPT 22214, 22216, and 63102. Our reviewer says 
that the records do not support that CPT 22214: osteotomy of spine, posterior or posterolateral approach, 1 
vertebral segment, lumbar was rendered in this case. The procedure details do not corroborate that an 
osteotomy was performed. Therefore, the records do not support that CPT 22214: osteotomy of spine, posterior 
or posterolateral approach, 1 vertebral segment, lumbar was rendered in this case. 
 
In terms of CPT 22216, the procedure details do not corroborate that an osteotomy was performed. Therefore, 
the records do not support that CPT 22216: osteotomy of spine, posterior or posterolateral approach, 1 vertebral 
segment, each additional vertebral segment (list separately in addition to primary procedure) was rendered in 
this case. 
 
In terms of CPT 63102 and CPT 63103, the procedure details do not corroborate a vertebral corpectomy having 
been performed. Therefore, the records do not support either of these codes having been performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 22214, 22216, 63102 and 63103 have not been met. Therefore, we decided that 
the Plan does not have to pay for 22214, 22216, 63102 and 63103. 
 
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.