Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for CPT codes 87798, 87624, 87640, and 87481. We decided that the Plan 
does not have to pay for CPT codes 87150, 87641, 87653 and 87500.  
 You asked the Plan to pay for laboratory services provided 87150,87641, 87500, 87798, 87624, 87640, 87653, 
87481 January 17, 2022. You say that the medical records provided support the necessity of the services in 
dispute. The Plan says that the records do not contain documentation to support coding criteria for CPT code 
87150. Medical records submitted do not demonstrate that the service provided was distinctly separate/different 
from the other testing completed. 
 
We decided that the Plan has to pay for CPT codes 87798, 87624, 87640 and 87481.  
 
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 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 the laboratory services. Our reviewer says 
that CPT codes 87798, 87624, 87640 and 87481 are supported in the medical records. Our physician reviewer 
found for CPT 87798, the laboratory report includes documentation of urinary tract infection pathogen panel. 
For CPT 87624, per laboratory report "HPV 16 negative; HPV 18 Negative". For CPT 87640, the laboratory 
report does include documentation of Staphylococcus aureus.  Laboratory report documents "S. aureus; not 
detected". For CPT 87481, the laboratory report does include documentation of candida species.  Per laboratory 
report: "C. albicans not detected". 
  
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 laboratory services have been met. Therefore, we decided that the Plan has 
to pay for CPT codes 87798, 87624, 87640, and 87481.  
 
We also decided that the Plan does not have to pay for CPT codes 87150, 87641, 87653 and 87500. 
 
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 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 CPT codes 87150, 87641, 87653 and 87500. 
Our reviewer says CPT codes 87150, 87641, 87653 and 87500 are not supported in the medical records. Our 
physician reviewer found for CPT 87150, the laboratory report does not include documentation of Culture 
typing, identification by nucleic acid. Was unable to cite report, as this procedure was not found in the medical 
record, and therefore cannot be verified. For CPT 87641 the laboratory report does not include documentation 
of Staphylococcus aureus, methicillin resistant. Was unable to cite report as this procedure was not found in 
medical record. For CPT 87500 the laboratory report does not include documentation of Vancomycin 
resistance. Was unable to cite report as this procedure was not found in medical record. For CPT 87653, the   
laboratory report does not include documentation of streptococcus, group B. Was unable to cite report as this 
procedure was not found in medical record. 
 
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 coeds 87150, 87641, 87653 and 87500 have not been met. Therefore, we 
decided that the Plan does not have to pay for CPT codes 87150, 87641, 87653 and 87500. 
 
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.