Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 20937, 20939, 63056, and 63057 rendered on 
February 17, 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 the records do not support the services billed. 
 
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 20937: 
 
Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial 
incision) (List separately in addition to code for primary procedure) 
 
CPT 20939: 
 
Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List 
separately in addition to code for 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) 
 
We asked our coder 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 not supported by the medical records. Our reviewer found that morselized tri-calcium phosphate 
soaked in bone marrow was added into the anterior disc space. The working channel was then removed. A 
titanium interbody tightly packed with morselized tri-calcium phosphate soaked in bone marrow was then 
inserted into the mid portion of the intervertebral disc space over a K-wire under biplanar fluoroscopic 
visualization and intraoperative neuromonitoring. The procedure details also cite a Jamshidi needle is placed in 
the upper right pedicle inside of the vertebral body and bone marrow has been aspirated through separate 
incision to introduce stem cells and mix into biologics. Therefore, the records do support CPT 20937 and CPT 20939 in this case.  
 
In terms of CPT 63057 and CPT 63057, the interpedicular and intradiscal space was significantly enlarged and 
disc height was restored towards normal anatomy therefore releasing pressure on the nerve roots. 
Physiologically, the spinal canal and lateral recess as well as forearm were bilaterally decompressed and the 
bones were confined to the borders of the disc space. This was performed at L3/4/5/S1. Therefore, the records 
also support CPT 63057 and CPT 63057 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 the services have been met. Therefore, we decided that the Plan has to pay for 
procedure codes 20937, 20939, 63056, and 63057 rendered on February 17, 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.