Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the chest x-ray. We decided that the Plan does not have to pay for the 
remaining x-rays.  
 
You asked the Plan to pay for the services provided. You say that the enrollee suffers from feeding difficulties 
due to dysphagia. The Plan says that the services were not the standard of care for the enrollee's condition. 
 We decided that the Plan has to pay for the chest x-ray.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary. 
 
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 the services provided. Our physician 
reviewer found that the enrollee has a past medical history of head and neck cancer, and dementia, who was 
evaluated for coughing and a hoarse vocal quality. Dysphagia symptoms were first noted on March 21, 2022. 
Feeding difficulties and difficulty swallowing were reported. The enrollee was edentulous, and her diet was 
mechanical soft. The enrollee was deemed to be at high risk for aspiration pneumonia. Examination was 
notable for wheezes and diminished breath sounds at the lung bases, more pronounced on the left. 
A modified barium swallowing study was performed which demonstrated increased A-P transport time with 
lingual pumping and oral residues, and a 2-3 second pharyngeal swallow delay. The documentation does 
support that the chest x-ray (code 71045) was indicated, and medically reasonable and necessary for the 
enrollee 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 provided have been met. Therefore, we decided that the Plan has to 
pay for the chest x-ray provided on March 25, 2022.  
 
We also decided that the Plan does not have to pay for the remaining x-rays. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
The file shows that a cervical spine x-ray, mandible x-ray, and teeth x-ray were provided. 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 the remaining x-rays. Our physician reviewer found that the 
enrollee dysphagia symptoms were noted and feeding difficulties and difficulty swallowing were reported. and 
her diet was mechanical soft. The enrollee was deemed to be at high risk for aspiration pneumonia. A modified 
barium swallowing study was performed which demonstrated increased A-P transport time with lingual 
pumping and oral residues, and a 2-3 second pharyngeal swallow delay. The available documentation does not 
support the medical necessity of the cervical spine, mandible, and teeth x-rays.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The file 
shows that a swallowing function radiologic exam (code 74230) and upper gastrointestinal tract radiologic 
exam (code 74240) were provided. The tests at issue included contrast media. These services are not covered 
under the portable x-ray provisions.   
 
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 remaining x-rays have not been met. Therefore, we decided that the Plan 
does not have to pay for the remaining x-rays provided on March 25, 2022. 
 
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.