Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the fourth unit of code 88377-59. We decided that the Plan does not 
have to pay for the services described by codes 88346 and 88350.  
 
You asked the Plan to pay for the fourth unit of code 88377-59. You say that this was all coded correctly based 
on information from CodeMap. The Plan says that these codes are not supported with the documentation 
provided. 
 
We decided that the Plan has to pay for the fourth unit of code 88377-59.  
 
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 asked our coding 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 fourth unit of code 88377-59. Our 
reviewer says that the documentation supports the fourth unit of 88377. Our coding reviewer found code 88377 
is defined as Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per 
specimen; each multiplex probe stain procedure. The lab results include 4 FISH Image results; therefore, all 4 
units of 88377 procedure should be paid.  
 
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 fourth unit of code 88377-59 have been met. Therefore, we decided that the 
Plan has to pay for the fourth unit of code 88377-59.  
 
We also decided that the Plan does not have to pay for the services described by codes 88346 and 88350. 
 
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 asked our 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 services described by codes 88346 and 88350. Our 
reviewer says that the documentation does not support payment for the other denied codes. Our reviewer found 
the code 88346 is defined as Immunofluorescence, per specimen; initial single antibody stain procedure. The 
physician's documentation does state that "Block A consisted of 2 Diff-Quick direct smears, 2 Pap direct smear 
and 1 H&E cell block and that Block A was selected for neotype Lung Profile." However, the lab report from 
Biocept does not clearly define how many distinct specimens were tested. As such, there is not enough 
information to validate this service. 
 
Code 88350 is defined as Immunofluorescence, per specimen; each additional single antibody stain procedure 
(List separately in addition to code for primary procedure). CPT 88350 is an add-on code, which requires the 
primary code to be eligible for reimbursement before it can be considered for reimbursement. CPT 88346, the 
primary code, does not meet criteria for reimbursement; therefore, CPT 88350 cannot be considered for 
separate reimbursement. 
 
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 services described by codes 88346 and 88350 have not been met. Therefore, 
we decided that the Plan does not have to pay for the services described by codes 88346 and 88350. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.