Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 27254. We decided that the Plan does not have to pay for 72190.  
 
You asked the Plan to pay for surgery and radiology services (procedure code 27254 and 72190) provided to 
the enrollee on April 1, 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 27254.   
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 27254 is "Open treatment 
of hip dislocation, traumatic, with acetabular wall and femoral head fracture, with or without internal or 
external fixation." 
 
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 27254. Our reviewer says that the records do 
support that CPT 27254: open treatment of hip dislocation, traumatic, with acetabular wall and femoral head 
fracture, with or without internal or external fixation was a separate and distinct procedure from CPT 27130: 
arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty) with or without 
autograft or allograft. The procedure notes cite that the posterior wall fracture fragment was reduced with a ball 
spike pusher after cleaning it. It reduced nicely. It was pinned with two 1.6 wires which was switched for 
2.0mm mini fragment screws x2. The posterior wall strap plate was contoured. It was 7 holes in length and was 
secured with 2 screws above and below the fracture supporting the posterior wall fragment well. This was 
performed prior to the hip arthroplasty procedure being performed. 
 
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 
27254.  
 
We also decided that the Plan does not have to pay for 72190. 
 
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 71290 is "Radiologic 
examination, pelvis; complete, minimum of 3 views."  
 
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 72190. Our reviewer says that the records do 
not support that CPT 72190: radiologic examination, pelvis, complete, minimum of 3 views was a separate and 
distinct procedure from CPT 27130: arthroplasty, acetabular and proximal femoral prosthetic replacement (total 
hip arthroplasty) with or without autograft or allograft. The 4/1/22 intraoperative imaging report was used to 
verify the correct placement of the total hip arthroplasty hardware. This is not a separate procedure. It would be 
considered a part of the global total hip arthroplasty procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 72190 have not been met. Therefore, we decided that the Plan does not have to 
pay for 72190. 
 
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.