Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87481, 87491, 87496, 87529, 87591, 87640, 87651, 87653, 87661 and 87798 provided on June 1, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 87481, 87491, 87496, 87529, 87591, 87640, 87651, 87653, 87661 and 87798 are not supported in the medical record. Specifically, the documentation submitted did not include documentation from the billing provider of performing this service: Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique; therefore, code 87481 cannot be verified.
The documentation submitted did not include documentation from the billing provider of performing this service: Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique; therefore, code 87491 cannot be verified.
The documentation submitted did not include documentation from the billing provider of performing this service: Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique; therefore, code 87496 cannot be verified.
The documentation submitted did not include documentation from the billing provider of performing this service: Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique; therefore, code 87529 cannot be verified. The documentation submitted did not include documentation from the billing provider of performing this service: Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique; therefore, code 87591 cannot be verified.
The documentation submitted did not include documentation from the billing provider of performing this service: Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique; therefore, code 87640 cannot be verified.
The documentation submitted did not include documentation from the billing provider of performing this service: Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique; therefore, code 87651 cannot be verified.
The documentation submitted did not include documentation from the billing provider of performing this service: Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique; therefore, code 87653 cannot be verified.
The documentation submitted did not include documentation from the billing provider of performing this service: Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, amplified probe technique; therefore, code 87661 cannot be verified.
The documentation submitted did not include documentation from the billing provider of performing this service: Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism; therefore, code 87798 cannot be verified.
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 coded 87481, 87491, 87496, 87529, 87591, 87640, 87651, 87653, 87661 and 87798 provided on June 1, 2020.