Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules also say that that the professional component of a diagnostic procedure furnished to a beneficiary in a 
hospital includes an interpretation and written report for inclusion in the beneficiary's medical record 
maintained by the hospital. (See 42 CFR 415.120(a).) Carriers generally distinguish between an interpretation 
and report of an x-ray or an electrocardiogram (EKG) procedure and a review of the procedure. A 
professional component billing based on a review of the findings of these procedures, without a complete, 
written report similar to that which would be prepared by a specialist in the field, does not meet the conditions 
for separate payment of the service. This is because the review is already included in the emergency 
department evaluation and management (E&M) payment. For example, a notation in the medical records 
saying fracture-tibia or EKG-normal would not suffice as a separately payable interpretation and report of the 
procedure and should be considered a review of the findings payable through the E&M code. An 
interpretation and report should address the findings, relevant clinical issues, and comparative data (when 
available). Generally, carriers must pay for only one interpretation of an EKG or x-ray procedure furnished to 
an emergency room patient. They pay for a second interpretation (which may be identified through the use of 
modifier -77) only under unusual circumstances (for which documentation is provided) such as a 
questionable finding for which the physician performing the initial interpretation believes another physician's 
expertise is needed or a changed diagnosis resulting from a second interpretation of the results of the 
procedure. You can find this information in the Centers for Medicare & Medicaid Services, Internet-Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 13, Section 100.1. 
 
The rules also say that if imaging studies (for example, radiographs, computerized tomography, magnetic 
resonance imaging) are repeated during the course of a radiological encounter due to substandard quality or 
need for additional views, only one unit of service for the appropriate code may be reported. If the radiologist 
elects to obtain additional views after reviewing initial films in order to render an interpretation, the Medicare 
policy on the ordering of diagnostic tests must be followed. The Current Procedural Terminology (CPT) code 
describing the total service shall be reported, even if the patient was released from the radiology suite and had 
to return for additional services. The CPT descriptors for many of these services refer to a minimum number 
of views. If more than the minimum number specified is necessary and no other more specific CPT code is 
available, only that service shall be reported. However, if additional films are necessary due to a change in the 
patients condition, separate reporting may be appropriate. You can find this rule in the Centers for Medicare & 
Medicaid Service, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 
IX, Section C. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.