Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for 92611- Motion fluoroscopic evaluation of swallowing function by cine 
or video recording. We decided that the Plan does not have to pay for 72040 - Radiologic examination, spine, 
cervical; 2 or 3 views; and 74240 - Radiologic examination, gastrointestinal tract, upper.  
 
You asked the Plan to pay for72040 - Radiologic examination, spine, cervical; 2 or 3 views; and 74240 - 
Radiologic examination, gastrointestinal tract, upper. 92611- Motion fluoroscopic evaluation of swallowing 
function by cine or video. You say that the services were medically necessary. The Plan says that the services 
are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We decided that the Plan has to pay for 92611- Motion fluoroscopic evaluation of swallowing function by 
cine or video.  
 
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 to pay for 92611- Motion fluoroscopic evaluation of 
swallowing function by cine or video. Our reviewer says that the requested 92611- Motion fluoroscopic 
evaluation of swallowing function by cine or video is considered medically reasonable and necessary in this 
case. Our physician reviewer found that a modified barium swallow after a CVA is reasonable in order to 
assess the possibility of aspiration. A modified barium swallow should be coded as a column 1 procedure using 
CPT 92611 and then video recording may be added with CPT 74230.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Motion fluoroscopic evaluation of swallowing function by cine or video have 
been met. Therefore, we decided that the Plan has to pay for a Motion fluoroscopic evaluation of swallowing 
function by cine or video.  
 
We also decided that the Plan does not have to pay for 72040 - Radiologic examination, spine, cervical; 2 
or 3 views; and 74240 - Radiologic examination, gastrointestinal tract, upper. 
 
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 to pay for 72040 - Radiologic examination, spine, 
cervical; 2 or 3 views; and 74240 - Radiologic examination, gastrointestinal tract, upper. Our reviewer says that 
the requested 72040 - Radiologic examination, spine, cervical; 2 or 3 views; and 74240 - Radiologic 
examination, gastrointestinal tract, upper is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that 72040 - Radiologic examination, spine, cervical; 2 or 3 views; and 74240 - 
Radiologic examination, gastrointestinal tract, upper were not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 72040 - Radiologic examination, spine, cervical; 2 or 3 views; and 74240 - 
Radiologic examination, gastrointestinal tract, upper have not been met. Therefore, we decided that the Plan 
does not have to pay for 72040 - Radiologic examination, spine, cervical; 2 or 3 views; and 74240 - Radiologic 
examination, gastrointestinal tract, upper. 
 
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.