Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for CPT 80307. We decided that the Plan does not have to pay for the rest 
of the codes.  
 
You asked the Plan to pay for the denied codes. You say that this should be paid for. The Plan says that the 
medical documentation submitted did not include lab results for this test 
 
We decided that the Plan has to pay for CPT 80307.  
 
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 
CPT 80307 is "Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or 
procedures, by instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, 
IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without 
chromatography, (DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes 
sample validation when performed, per date of service." 
 
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 for CPT 80307. Our reviewer says that this code is 
supported in the medical records. Our physician reviewer found that the code - CPT 80307 - for presumptive 
screening is supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPT 80307 have been met. Therefore, we decided that the Plan has to pay for 
CPT 80307.  
 
We also decided that the Plan does not have to pay for the rest of the codes. 
 
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 
the rest of the denied codes is: 
 
CPT 80157: 
 
Carbamepazine; free 
 
CPT 80159: 
 
Clozapine 
 
CPT 80162: 
 
Digoxin; total 
 
CPT 80173: 
 
Haloperidol 
 
CPT 80177: 
 
Levetiracetam 
 
CPT 80201: 
 
Topiramate 
 
HCPCS G0483: 
 
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.
 
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 for these services. Our reviewer says that the medical 
records do not support the denied codes. Our physician reviewer found that the enrollee was prescribed a 22+ 
drug class drug testing (definitive) via serum including haloperidol and others. The records state that urine 
testing was performed, but no serum venipuncture was performed. Clarification was not noted in the provided 
documentation. Also, it was not explained why the enrollee required definitive drug testing for drug classes 
unrelated to his regimen and treatment plan and prior presumptive results. Therefore, this request for the codes 
80157, 80177, 80201, 80162, 80159, 80173, G0483 were not supported by the provided documentation. 
 
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 rest of the codes have not been met. Therefore, we decided that the Plan 
does not have to pay for the rest of the codes. 
 
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.