Post op diagnosis: Cervical spondylosis, cervical radiculopathy, neck pain, chronic pain syndrome, & history of previous cervical spine fusion

Procedures performed: C4-5 anterior cervical discectomy & decompression, arthrodesis C4-5 using Progenix Plus allograft, insertion of interbody cage device at C4-5 using the Titan Endoskeleton titanium cage, anterior cervical instrumentation C4-5 using the Medtronic Atlantis Elite anterior cervical plating system, removal of instrumentation from C5-7, & intraoperative monitoring of motor evoked potentials, SSEPs & EMG.

What was billed: 22551, 20930, 22853, 22845-59, & 22855.

Insurance initially denied CPT 22845-59 for bundling. I submitted an appeal stating that 22845-59 represented the application of the anterior cervical plating system and modifier -59 had been appended to it to indicate it is separate from 22853. I attached a copy of the operative report. Appeal was denied. From the letter I received…." Per NCCI: HCPCS/CPT code descriptors of two codes are often the basis of an NCCI PTP edit. If two HCPCS/CPT codes describe redundant services, they should not be reported separately. We also applied the rule for modifier 59. Although the modifier may or may not be appended, the rule is applicable in this situation." Then the letter goes on the give the NCCI for modifier 59. So my initial appeal was denied.

I then submitted a second level appeal. I included not only the operative report but manufacturer information for both devices. In my letter I pointed out that the plating system could not be an integral part of the cage because they were from two different manufactures. I also submitted a screen shot of the CCI edit effective April 1, 2017 showing that use of modifier 59 is allowed for 22845.

Now my second level appeal is being denied as well, for the same reason they gave initially.

What am I missing here?????? Should spinal instability be documented as well to indicate medical necessity of the plating system? Or do they not want the modifier 59???

I’m about to pull my hair out on this one …..

Any input, guidance, or wisdom is greatly appreciated!