Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 36224, 36227, 76937, 
75894, and 75898. We decided that the Plan does not have to pay for the services described by procedure 
code(s) 61624.  
 
You asked the Plan to pay for codes 61624, 36224, 36227, 76937, 75894, and 75898 billed for date of service 
October 4, 2022. You say that codes 61624, 36224, 36227, 76937, 75894, and 75898 should be paid as billed 
because they are supported in the documentation. The Plan says that 61624 is denied because this service is 
included in the global surgery package of another procedure. 36224, 36227, 76937, 75894, and 75898 were 
handled as an original decision reopen for New and Material Evidence, therefore no coverage decision was 
made. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 36224, 36227, 76937, 
75894, and 75898.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 36224, 36227, 76937, 75894, 
and 75898.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
61624. 
 
The Plan follows Medicare rules. Medicare rules say that modifier -58 should be used to describe staged or 
related procedures done in the postoperative period of the first procedure. Medicare rules also say modifier -79 
is used to indicate an unrelated procedure by the same physician during a postoperative period. 
 
We looked at the file and Medicare rules. We confirmed that the enrollee was still in the 90-day postoperative 
period for the procedure coded as 61312 performed on September 28, 2022, when the procedure coded as 
61624 was performed by the same provider. We also confirmed that no global surgery modifiers were billed 
with code 61624. Based on this information, we decided that Medicare rules for coverage of the services 
described by procedure code(s) 61624 have not been met. Therefore, we decided that the Plan does not have to 
pay for the services described by procedure code(s) 61624. 
 
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.