Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 63047 rendered on April 18, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that procedure code 63047 is considered inclusive to CPT 22633. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 the services. Our reviewer says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found that the 
enrollee was being treated for spinal stenosis of the lumbar region with neurogenic claudication and 
intervertebral disc disorders with radiculopathy of the lumbar region. She underwent an L3-4 laminectomy and 
partial facetectomy for decompression of the central canal, the lateral recess, and the foramen bilaterally; L4-5 
laminectomy and partial facetectomy for decompression of the central canal, the lateral recess, and the foramen 
bilaterally; L4-5 transforaminal lumbar interbody fusion with placement of expandable titanium cage; L4-5 
posterior and posterolateral instrumentation fusion with use of pedicle screws and rods; use of local bone 
autograft; use of bone allograft; and laminectomy with primary repair of the intraoperative durotomy on 
4/18/23. The procedure details cite a laminectomy was performed at L3-4 and then L4-5. A central 
laminectomy was performed to allow for adequate decompression of the central canal and the lateral recess 
bilaterally. The ligamentum flavum was identified and the thickened ligament was removed centrally to allow 
for adequate central decompression of the spinal canal at the L4 level. The high-speed Stryker drill was used to 
complete the central laminectomy and facetectomy by removing the inferior articulating process bilaterally as it 
was disconnected from the pars. These pieces of bone were passed to the back table to be crushed down to the 
bone meal which will later be used as a local bone autograft. A laminectomy was performed with a high-speed 
drill to collect all the bone dust. The central decompression, the lateral recess decompression, and foraminal 
decompression was performed bilaterally at the L4-5. The above was performed prior to the discectomies 
performed for the lumbar fusion. The records support this code. 
 
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 
procedure code 63047 rendered on April 18, 2023.  
 
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.