Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80157, 80177, 80201,80162, 80159, 80173) provided to the enrollee on June 3, 2020.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

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 laboratory services. Our physician reviewer found the review indicates that CPT code 80157 remains not supported. The documentation submitted did not support that Carbamazepine; free testing was performed with blood sampling. Blood specimen collection is by venipuncture, however, the lab requisition states a urine specimen was collected; therefore, the billed service cannot be verified. CPT code 80177 remains not supported. The documentation submitted did not support that Levetiracetam testing was performed with blood sampling. Blood specimen collection is by venipuncture, however, the lab requisition states a urine specimen was collected; therefore, the billed service cannot be verified. CPT code 80201 remains not supported. The documentation submitted did not support that Topiramate testing was performed with blood sampling. Blood specimen collection is by venipuncture, however, the lab requisition states a urine specimen was collected; therefore, the billed service cannot be verified. Of note, the submitted blood/serum requisition did not contain the billed test. It is noted multiple attempts were made to obtain additional information from the provider. CPT code 80162 remains not supported. The documentation submitted did not support that Digoxin; total testing was performed with blood sampling. Blood specimen collection is by venipuncture, however, the lab requisition states a urine specimen was collected; therefore, the billed service cannot be verified. Of note, the submitted blood/serum requisition did not contain the billed test. It is noted multiple attempts were made to obtain additional information from the provider. CPT code 80159 remains not supported. The documentation submitted did not support that Clozapine testing was performed with blood sampling. Blood specimen collection is by venipuncture, however, the lab requisition states a urine specimen was collected; therefore, the billed service cannot be verified. Of note, the submitted blood/serum requisition did not contain the billed test. It is noted multiple attempts were made to obtain additional information from the provider. CPT code 80173 remains not supported. The documentation submitted did not support that Haloperidol testing was performed with blood sampling. Blood specimen collection is by venipuncture, however, the lab requisition states a urine specimen was collected; therefore, the billed service cannot be verified. Of note, the submitted blood/serum requisition did not contain the billed test. It is noted multiple attempts were made to obtain additional information from the provider. There was no clinical rationale for the obtained laboratory tests. The review has determined that the denied services were not supported by the medical records.

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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80157, 80177, 80201,80162, 80159, 80173) provided to the enrollee on June 3, 2020.