Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for G0483. We decided that the Plan does not have to pay for 82542.  
 
You asked the Plan to pay for definitive drug testing, 22 or more drug classes (G0483, 82542) provided to the 
enrollee on April 22, 2022.. You say that this should be paid for. The Plan says that the documentation does not 
support the services noted in the claim. 
 
We decided that the Plan has to pay for G0483.   
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 
code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual 
drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited 
to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., 
ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed." 
 
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 for G0483. Our reviewer says that the use of G0483 is 
appropriate and supported in the medical records. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
G0483.  
 
We also decided that the Plan does not have to pay for 82542. 
 
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 
code 82542 is "Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere 
specified." 
 
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 for CPT 82542. Our reviewer found that there is an 
edit relationship CPT 82542 and G0483. There are not sufficient medical records to support the use of modifier 
-59 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 82542 have not been met. Therefore, we decided that the Plan does not have to 
pay for 82542. 
 
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.