Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81226, 81227, 81402, 81291, 81479, 81225, 81230, 81231 and 81380) provided to the enrollee on July 2, 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 covered.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. The enrollee had molecular pharmacogenetic testing on July 2, 2020. The denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel.

CPT code 81226 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on July 2, 2020, and received by the lab on July 6, 2020. Of note, the enrollee resides in California (CA) and the billing laboratory is located in Pennsylvania (PA); therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider.

CPT code 81227 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on July 2, 2020, and received by the lab on July 6, 2020. Of note, the enrollee resides in CA and the billing laboratory is located in PA; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider.

CPT code 81227 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on July 2, 2020, and received by the lab on July 6, 2020. Of note, the enrollee resides in CA and the billing laboratory is located in PA; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider.

CPT code 81291 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.

Also, the laboratory results submitted indicate the specimen was collected on July 2, 2020, and received by the lab on 07/06/2020. Of note, the enrollee resides in CA and the billing laboratory is located in PA; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider.

CPT code 81402 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on July 2, 2020, and received by the lab on July 6, 2020. Of note, the enrollee resides in CA and the billing laboratory is located in PA; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81226, 81227, 81402, 81291, 81479, 81225, 81230, 81231 and 81380) provided to the enrollee on July 2, 2020.