Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 87798 and 87641. We decided that the Plan does not 
have to pay for procedure codes 87150, 87481 and 87653.  
 
You asked the Plan to pay for laboratory services provided on June 24, 2022. You say that these services were 
necessary and were reported correctly. The Plan says that the payment for these services is included in the 
payment for codes 87801 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 decided that the Plan has to pay for procedure codes 87798 and 87641.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
87798 and 87641 are a column II codes to column I code 87150; however, codes 87798 and 87641 were billed 
with a modifier. 
 
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 codes 87798 and 87641. Our reviewer says that the use of the 
91 modifier is appropriate in this case. Our reviewer found that these services are supported as billed with the 
91 modifier for separate payment. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87798 and 87641 have been met. Therefore, we decided that 
the Plan has to pay for procedure codes 87798 and 87641.  
 
We also decided that the Plan does not have to pay for procedure codes 87150, 87481 and 87653. 
 
In this case, we have confirmed that codes 87481 and 87653 are column II codes to column I codes 87801 
and/or 87150. These services have not been billed with an appropriate modifier to bypass the edit. Based on the 
claim submitted, Medicare billing criteria have not been met. In addition, we have confirmed that code 87150 
is a column II code to column I code 87500; however, code 87150 was billed with a modifier. 
 
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 procedure code 87150. Our reviewer says 
that modifier 91 is not supported for this code in this case.  
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150, 87481 and 87653 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87150, 87481 and 87653. 
 
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.