Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 22614. We decided that the Plan does not have to pay for 22850.   
You asked the Plan to pay for surgical services (procedure code 22614 and 22850) rendered on December 15, 
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 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. 
 
In this case, the CPT Code Manual definition of CPT 22614 is "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 CPT 22614. Our reviewer says that the procedure 
details cite O-arm was used to guide placement of the screws from L5-S2. L3 and L4 replaced in the sites 
where they previously had been. Implant placement was verified. On the left, the interspace between L4 and L5 
was opened further by distracting the space using a temporary rod and the screws at L4 and L5. This supports 
the posterior fusion at more than one level. Therefore, the records do support that CPT 22614 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 the services have been met. Therefore, we decided that the Plan has to pay for 
22614.  
 
We also decided that the Plan does not have to pay for 22850. 
 
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 22850 is "Removal of posterior nonsegmental 
instrumentation (eg, Harrington rod)." 
 
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 22850. Our reviewer says that the procedure 
details cite L3 and L4 replaced in the sites where they previously had been. Implant placement was verified. On 
the left, the interspace between L4 and L5 was opened further by distracting the space using a temporary rod 
and the screws at L4 and L5. The procedure details do not clearly document the removal of the posterior 
instrumentation. Therefore, the records do not clearly support CPT 22850 as a separate and distinct procedure 
from CPT 22842. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 22850 have not been met. Therefore, we decided that the Plan does not have to 
pay for 22850. 
 
 
 
 
 
 
 
 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.