Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for CPT 78812. We decided that the Plan does not have to pay for CPT 
70490, 71250, CPT 74176.  
 
You asked the Plan to pay for the radiology services. You say that this should be paid for. The Plan says that 
the service is not supported without requested documentation. 
 
We decided that the Plan has to pay for CPT 78812.  
 
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 code 78812 is "Positron emission tomography (PET) 
imaging." 
 
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 78812. Our reviewer says that the records 
support this code. Our physician reviewer found that there is a valid indication and documentation of a PET/CT 
scan (CPT 78812). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
 
 
Medicare rules for coverage of CPT 78812 have been met. Therefore, we decided that the Plan has to pay for 
CPT 78812.  
 
We also decided that the Plan does not have to pay for CPT 70490, 71250, CPT 74176. 
 
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 the denied codes is: 
 
CPT 70490: 
 
Computed tomography, soft tissue neck 
 
CPT 71250: 
 
Computed tomography, thorax 
 
CPT 74176: 
 
Computed tomography, abdomen and pelvis 
 
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 the remaining codes. Our reviewer says that the 
records do not support these codes. Our physician reviewer found that the the remainder of the charges are 
related to the separate interpretation of the various organ system on the CT images.  For example 71250, 74176 
and 70490 are charges related to the interpretation of the CT images of the chest, abdomen and pelvis.  As such 
CMS allows for the one charge for the PET/CT which is 78812-26 and not the remaining charges since the 
description of the PET/CT includes the CT portion of the exam. Separate charges for CT interpretation are not 
allowed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPT 70490, 71250, CPT 74176 have not been met. Therefore, we decided that 
the Plan does not have to pay for CPT 70490, 71250, CPT 74176. 
 
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.