Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for Stereotactic computer-assisted (navigational) procedure (61783)
provided to the enrollee on December 16, 2021.
You asked the Plan to pay for this claim as billed. You say that this claim should be paid. The Plan denied your
request. The Plan says that Medicare billing criteria were not met. Maximus decided the appeal as favorable but
used an inappropriate letter for the decision. The Plan requested a reopen and clarification of the decision.
Our Medical Director looked at the original decision and the reopen request. At issue is the coding of 61783 -
Stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to code for primary
procedure). The enrollee has diagnoses of M48.061 - Spinal stenosis, lumbar region without neurogenic
claudication, and M47.816 - Spondylosis without myelopathy or radiculopathy, lumbar region.
The procedure performed was Single position right L2-3 direct lateral interbody fusion, L2-3 instrumented
posterior spinal fusion, instrumentation, allograft, autograft, bone morphogenetic protein, spine robot assisted
navigation, neuro monitoring.
The Plan argued that the operative report did not include documentation of a spinal stereotactic computerassisted
(navigational) procedure (listed separately in addition to code for primary procedure); therefore this
code cannot be verified. Per the billing guidelines, the physician performs spinal procedures utilizing
stereotactic computer-assisted navigation. The Plan stated the billed code may only be assigned in conjunction
with the primary procedure when the physician uses a computer (e.g. Stealth Station) to assist with coordinate
determination established with a computed tomography (CT ) (including O-Arm) or magnetic resonance
imaging (MRI )scan. The Plan states the operative report submitted for review does not provide this required
documentation and code 61783 cannot be verified.
Our Medical Director notes the following: to cite the operative report; "Next, the robot was brought in and we
merged the fluoroscopic images to the preoperative CT scan that was fed into the robot. Using robotic
navigation, pedicle screws were now placed into L2 and L3 percutaneously with good fixation. Neuro
monitoring was used during the insertion and good thresholds were noted on testing." Per the National Correct
Coding Initiative Policy Manual for Medicare Services, Revision Date: January 1, 2021; regarding the
submitted (CPT) code of 61783, the physician performs cranial or spinal procedures utilizing stereotactic
computer-assisted navigation. These codes may only be assigned in conjunction with the primary procedure
when the physician uses a computer to assist with coordinate determination established with a CT or MRI scan.
Report 61781 for intradural cranial procedures; 61782 for extradural cranial procedures; and 61783 for spinal
procedures. The Operative Report dated December 16, 2021, documents, "Next, the robot was brought in and
we merged the fluoroscopic images to the preoperative CT scan that was fed into the robot. Using robotic
navigation, pedicle screws were now placed int L2 and L3 percutaneously with good fixation. Neuro
monitoring was used during the insertion and good thresholds were noted on testing."
Our Medical Director has concluded that code 61783 is an add-on code which describes computer-assisted
navigational procedures of the cranium or spine. Stereotactic navigational procedures are usually performed to
identify anatomy for precise treatments and to avoid vital structures. The documentation in the Operative
Report supports that a stereotactic navigational procedure was performed in this case.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this claim as billed have been met. Therefore, we decided that the Plan has to
pay for Stereotactic computer-assisted (navigational) procedure (61783) provided to the enrollee on December
16, 2021.
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.