Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 22214, 22216, 22633, 22634, 22840, 22853, 
63047, and 63048 billed for October 27, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 22214, 22216, 22633, 22634, 22840, 22853, 63047, and 63048 are not 
supported. 
 
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 22214 is osteotomy of spine, posterior or posterolateral 
approach, 1 vertebral segment; lumbar. The definition of code 22216 is osteotomy of spine, posterior or 
posterolateral approach, 1 vertebral segment; each additional vertebral segment (List separately in addition to 
primary procedure). The definition of code 22633 is Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare 
interspace (other than for decompression), single interspace, lumbar. The definition of code 22634 is 
arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including 
laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single 
interspace, lumbar; each additional interspace (List separately in addition to code for primary procedure). The 
definition of code 22840 is posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle 
fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw 
fixation) (List separately in addition to code for primary procedure). The definition of code 22853 is insertion 
of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for 
device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with 
interbody arthrodesis, each interspace (List separately in addition to code for primary procedure). The 
definition of code 63047 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; lumbar. The definition of code 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 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 these services. Our reviewer says that procedure codes 
22214, 22216, 22633, 22634, 22840, 22853, 63047, and 63048 are not supported. Our reviewer found the brief 
operative note describes a rigid spine and does not describe the levels of any surgery. The records do not 
support proper billing of any of the codes at issue. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 22214, 22216, 22633, 22634, 22840, 22853, 63047, and 63048 billed for 
October 27, 2021.