Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 87632. We decided that the Plan does not have to pay 
for procedure codes 87503, 87634 and 87801-XU.  
 
You asked the Plan to pay for procedure codes 87503, 87632, 87634 and 87801-XU billed for date of service 
January 12, 2022. You say that these services were necessary and were billed correctly. The Plan says that 
these services were not billed in accordance with Medicare guidelines. 
 
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 decided that the Plan has to pay for procedure code 87632.  
 
We asked our coder 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 procedure code 87632. Our reviewer says that procedure 
code 87632 should be paid. Our physician reviewer found that this code was accurately billed and is supported 
in the medical record.  
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87632 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 87632.  
 
We also decided that the Plan does not have to pay for procedure codes 87503, 87634 and 87801-XU. 
 
In this case, we have confirmed that code 87634 is a column II code to column I code 87632. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. 
 
We asked our coder 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 procedure codes 87503 and 87801-XU. Our reviewer says 
that the records provided do not support these services. Our physician reviewer found that procedure code 
87503 has been billed following Medicare rules as procedure code 87502 should be billed in conjunction with 
87503. In addition, it is highly unlikely that more than one unit of 87503 would be billed for a single date of 
service, but more than one unit was billed. Medical documentation does not support the reported quantity. In 
addition, procedure code 87801-XU is a column II code to column I code 87632. Although this service was 
billed with a modifier to bypass this edit, the use of this modifier is not properly supported and documented to 
override the edit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87503, 87634 and 87801-XU have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87503, 87634 and 87801-XU. 
 
 
 
 
 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.