Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an infectious disease panel (87801, 87798, 87481) provided 
on April 26, 2022. 
 
You asked the Plan to pay for an infectious disease panel. You say that this test was essential and was provided 
with other medically necessary services. The Plan denied your request. The Plan says it is not medically 
necessary to verify a fungal infection with an infectious disease PCR (polymerase chain reaction) panel. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 to pay for an infectious disease panel. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that it is well established in the medical documentation that this enrollee is suffering 
with a thick, painful, dystrophic right hallux toenail that has not responded to over-the-counter antifungal medication. The medical documentation advises that the enrollees podiatrist has taken a sample of the right 
hallux toenail for PCR testing. The podiatrist advises that the PCR testing is necessary in order to adequately 
treat the enrollees dystrophic toenail. When dealing with onychodystrophy, it is certainly important to 
decipher what pathogen or pathogens are causing the toenail to become dystrophic. Longtime standard of care 
tests includes potassium hydroxide (KOH) and fungal culture. These tests are straightforward, inexpensive, and 
do provide significant information which would allow a physician to treat the enrollees onychodystrophy 
appropriately. Medicare guidelines advise that Medicare will pay for items or services that are reasonable and 
necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed 
body member. These services must be safe and effective, not mainly for the convenience of the enrollee or the 
physician, not experimental or investigational, and appropriate in that the test should be furnished in 
accordance with accepted standards of medical practice for the diagnosis or treatment of the enrollees 
condition or to improve the functioning of a malformed body member. The test must be furnished in a setting 
appropriate to the enrollees medical needs and conditions and one that meets but does not exceed the 
enrollees medical need. The medical documentation does not support that this enrollees right hallux toenail 
specimen has undergone KOH and fungal culture testing. It appears that the PCR testing of the toenail exceeds 
this enrollees medical needs. Therefore, it is my opinion that the requested infectious disease panel was not 
medically reasonable or necessary in this case.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an infectious disease panel have not been met. Therefore, we decided that the 
Plan does not have to pay for an infectious disease panel (87801, 87798, 87481) provided on April 26, 2022.