Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 63048, 63020 and 63045. We decided that the Plan 
does not have to pay for procedure codes 63710 and 63035.  
 
You asked the Plan to pay for procedure codes 63035, 63710, 63048, 63020 and 63045 billed for date of 
service May 8, 2023. You say that these services were necessary and are supported in the medical record. The 
Plan says that these codes are not supported as 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 code 63710 is dural graft, spinal. The CPT Code Manual 
definition of code 63035 is laminotomy (hemilaminectomy), with decompression of nerve root(s), including 
partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, 
cervical or lumbar (List separately in addition to code for primary procedure). The CPT Code Manual 
definition of code 63048 is laminectomy, facetectomy and foraminotomy (unilateral or bilateral with 
decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single 
vertebral segment; cervical. The CPT Code Manual definition of code 63020 is laminotomy 
(hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or 
excision of herniated intervertebral disc; 1 interspace, cervical. The CPT Code Manual definition of code 
63045 is laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, 
foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar 
(List separately in addition to code for primary procedure). 
 
In addition, we have confirmed that codes 63020 and 63045 are column II codes to column I code 22210; 
however, codes 63020 and 63045 were each billed with a modifier. 
 
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 procedure codes 63035, 63710, 63048, 63020 and 63045. 
Our reviewer says that some of these codes are not supported for payment; however, some codes are 
adequately supported in the records provided. Our reviewer found that the operative report does not mention 
placement of a graft of the spinal dura or laminotomy with decompression of nerve roots performed at an 
additional inter-space level. Therefore, codes 63710 and 63035 are not supported. The documentation does 
support code 63048, as the operative report shows that laminectomy, facetectomy and foraminotomy were 
performed at additional vertebral segments after the initial segment. In addition, codes 63020 and 63045 with 
modifier 59 are supported as separate and distinct procedures. The record supports that they were performed 
independently to treat stenosis and decompress the spine and nerve roots and were not related to the osteotomy 
reported with 22210. 
 
We decided that the Plan has to pay for procedure codes 63048, 63020 and 63045.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 63048, 63020 and 63045 have been met. Therefore, we 
decided that the Plan has to pay for procedure codes 63048, 63020 and 63045.  
 
We also decided that the Plan does not have to pay for procedure codes 63710 and 63035. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 63710 and 63035 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 63710 and 63035. 
 
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.