Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 20, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there is a more appropriate code to describe the services provided.  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, the CPT Code Manual definition of the denied codes is:  CPT 87486:  Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, amplified probe technique  CPT 87496:  Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique  CPT 87498:  Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique, includes reverse transcription when performed  CPT 87532:  Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, amplified probe technique  CPT 87541:  Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, amplified probe technique  CPT 87581:  Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, amplified probe technique  CPT 87631:  Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets  CPT 87640:  Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique  CPT 87798:  Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism  HCPCS U0003:  Infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, making use of high throughput technologies as described by cms-2020-01-r  HCPCS U0005:  Infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, cdc or non-cdc, making use of high throughput technologies, completed within 2 calendar days from date of specimen collection (list separately in addition to either hcpcs code u0003 or u0004) as described by cms-2020-01-r2  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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the documentation supports more than five targets. Therefore, there is a more appropriate code for the services rendered. Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 20, 2021.