Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 87641, 87653, 87500, 
87640 and 87798. We decided that the Plan does not have to pay for the services described by procedure 
code(s) the 5 units of code 87481.  
 You asked the Plan to pay for the lab testing provided on May 19, 2021, billed with codes 87641, 87653, 
87500, 87640, 87798, and 5 units of code 87481.. You say that it is felt that these tests should be covered. The 
Plan says that code 87481 has been billed with an unsupported number of units. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 87641, 87653, 87500, 
87640 and 87798.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan provided a remittance only for the single code that was addressed but did not submit a copy 
of the full claim. The provider included a copy of the claim with the codes above along with a document from 
the Plan that appears to show that all codes were in fact denied. There is no evidence that there was a valid 
reason for these codes not to be addressed. As the Plan forfeited its opportunity to provide a denial rationale for 
these services, we find that the denial of payment is not supported. Therefore, we decided that the Plan has to 
pay for the services described by procedure code(s) 87641, 87653, 87500, 87640 and 87798.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) the 5 
units of code 87481. 
 
The Plan follows Medicare rules. Medicare rules say that The Plan must follow Medicare rules. Medicare rules 
say that providers must report the actual number of units provided for each procedure 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 services described by procedure code(s) 
the 5 units of code 87481. Our reviewer says that the number of units reported for code 87641 is not supported. 
Our coder found code 87481 is defined as Infectious agent detection by nucleic acid (DNA or RNA); Candida 
species, amplified probe technique. The record shows that only two Candida species were tested. As such, the 
number of units billed is not appropriate. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services described by procedure code(s) the 5 units of code 87481 have not 
been met. Therefore, we decided that the Plan does not have to pay for the services described by procedure 
code(s) the 5 units of code 87481. 
 
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.