Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 20931 and 22614. We decided that the Plan does not have to pay for 
22842.  
 
You asked the Plan to pay for procedure codes 20931, 22614, and 22842 rendered on December 20, 2022.. 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 20931 and 22614.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of the overturned codes is: 
 
CPT 20931: 
 
Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure) 
 
CPT 22614: 
 
Arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace (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 these codes. Our reviewer says that in terms of CPT 
20931, the records do support that it was rendered. The procedure details cite that Gelfoam soaked in thrombin 
was used in the lateral gutter to assist with hemostasis and placement of the Surgicel in the lateral gutters and 
over the exposed thecal sac were noted to have been performed. 
 
In terms of CPT 22814, the procedure details cite attention was directed to the placement of the pedicle screw 
fixation both at L4 and L5 bilaterally. They were connected with a 40mm rod. 
 
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 
20931 and 22614.  
 
We also decided that the Plan does not have to pay for 22842. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 22842 is "Posterior 
segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 
vertebral segments (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 22842. Our reviewer says that the procedure 
details cite attention was directed to the placement of the pedicle screw fixation both at L4 and L5 bilaterally. 
They were connected with a 40mm rod. There was only one level in this procedure. Therefore, the records do 
not support that CPT 22842 was rendered 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 22842 have not been met. Therefore, we decided that the Plan does not have to 
pay for 22842. 
 
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.