Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 63048. We decided that the Plan does not have to pay for 22859 and 
63047.  
 
You asked the Plan to pay for procedure codes 22859, 63047, and 63048 rendered on February 27, 2023.. You 
say that this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 63048.  
 
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 CPT 63048 is "Laminectomy, facetectomy and foraminotomy 
(unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or 
lateral recess stenosis]), single vertebral segment; each additional vertebral segment, cervical, thoracic, or 
lumbar (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 for CPT 63048. Our reviewer says that the procedure 
details cite Type 1 osteotomies or medial facetectomies were fashioned at T11-12 and T12-L1 bilaterally. Type 
2 or Smith Peterson osteotomies were fashioned at L1-2 with decortication of the facet joints and removal of 
1cm of bone from the inferior articular processes of L1 and the superior articular processes of L2 on both sides 
to complete the osteotomy. Therefore, the records support CPT 63048 in this case. 
 
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 
63048.  
 
We also decided that the Plan does not have to pay for 22859 and 63047. 
 
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 upheld codes are: 
 
CPT 22859: 
 
Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to 
intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List 
separately in addition to code for primary procedure) 
 
CPT 63047: 
 
Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda 
equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar 
 
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 these codes. Our reviewer says that in terms of CPT 
22859, the procedure details cite DePuy conduit cages were tried and then deployed into the disc space at L5-
S1 bilaterally; however, there was an interbody arthrodesis performed at this level. Therefore, the records do 
not support this code.  
 
In terms of CPT 63047, the procedure details cite Type 1 osteotomies or medial facetectomies were fashioned 
at T11-12 and T12-L1 bilaterally. Type 2 or Smith Peterson osteotomies were fashioned at L1-2 with 
decortication of the facet joints and removal of 1cm of bone from the inferior articular processes of L1 and the 
superior articular processes of L2 on both sides to complete the osteotomy. The facetectomies were performed 
with the osteotomies. Therefore, the records do not 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 22859 and 63047 have not been met. Therefore, we decided that the Plan does 
not have to pay for 22859 and 63047. 
 
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.