Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for all denied CPT codes except for CPT 81283. We decided that the Plan does not have to pay for CPT 81283.
You asked the Plan to pay for all denied CPT codes except for CPT 81283. You say that this should be paid for. The Plan says that the submitted documentation did not contain laboratory results from the billing provider.
We decided that the Plan has to pay for all denied CPT codes except for CPT 81283.
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 denied codes is: CPT 81225: CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *8, *17) CPT 81226: CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) CPT 81230: CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug metabolism), gene analysis, common variant(s) (eg, *2, *22)
CPT 81231: CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *7) CPT 81240: F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 20210G>A variant CPT 81241: F5 (coagulation factor V) (eg, hereditary hypercoagulability) gene analysis, Leiden variant CPT 81328: SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) (eg, *5) CPT 81335: TPMT (thiopurine S-methyltransferase) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3) CPT 81232: DPYD (dihydropyrimidine dehydrogenase) (eg, 5-fluorouracil/5-FU and capecitabine drug metabolism), gene analysis, common variant(s) (eg, *2A, *4, *5, *6) CPT 81408: Molecular pathology procedure, Level 9 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 the denied codes above. Our reviewer says that the medical records support the coding of these denied codes. Our physician reviewer found that the denial of these codes should be overturned. Laboratory results for these codes have been provided. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of all denied CPT codes except for CPT 81283 have been met. Therefore, we decided that the Plan has to pay for all denied CPT codes except for CPT 81283.
We also decided that the Plan does not have to pay for CPT 81283.
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 81283 is "IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis, rs12979860 variant." 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 81283. Our reviewer says that the medical records do not support this code. Our physician reviewer found a laboratory result for this code has not been provided.
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 81283 have not been met. Therefore, we decided that the Plan does not have to pay for CPT 81283.