Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunohistochemistry (88341 and 88342) and surgical 
pathology (88305) provided on October 15, 2019. 
 
You asked the Plan to pay for the immunohistochemistry and surgical pathology. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 88341 is mmunohistochemistry or 
immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in 
addition to code for primary procedure). 
 
The CPT Code Manual definition of code 88342 is immunohistochemistry or immunocytochemistry, per 
specimen; initial single antibody stain procedure. 
 
The CPT Code Manual definition of code 88305 is  Level IV - Surgical pathology, gross and microscopic 
examination Abortion - spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis 
Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical 
margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy 
Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy 
Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, 
fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection 
Kidney, biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy - without uterus Lip, biopsy/wedge 
resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, biopsy Nasal mucosa, biopsy 
Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or 
without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary 
tumor Placenta, other than third trimester Pleura/pericardium - biopsy/tissue Polyp, cervical/endometrial Polyp, 
colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus, 
paranasal biopsy Skin, other than cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other 
than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than 
tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy 
Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse 
Vagina, biopsy Vulva/labia, biopsy. 
 
We asked our coder 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 immunohistochemistry and surgical pathology. Our 
reviewer says that CPT code 88341 does not meet criteria for billing or reimbursement consideration. The 
medical records provided do not include documentation of 6 additional units of  Immunohistochemistry or 
immunocytochemistry, per specimen; each additional single antibody stain procedure. CPT code 88342 does 
not meet criteria for billing or reimbursement consideration because the medical records provided do not 
include documentation of an additional unit of mmunohistochemistry or immunocytochemistry, per specimen; 
initial single antibody stain procedure being performed. Our reviewer found CPT code 88305 does not meet 
criteria for billing or reimbursement consideration because the medical records provided do not include 
documentation of this service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the immunohistochemistry and surgical pathology have not been met. 
Therefore, we decided that the Plan does not have to pay for the immunohistochemistry (88341 and 88342) and 
surgical pathology (88305) provided on October 15, 2019.