Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 4, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The records submitted show that specimens were collected on April 23, 2019. The test was ordered December 20, 2021. The specimen was received on December 23, 2021. The Medicare general rules state that the date of service for a clinical laboratory test or the technical component of physician pathology service must be the date the specimen was collected. There are 3 exceptions including Tests/Services Performed on Stored Specimens. In the case of a test/service performed on a stored specimen, if a specimen was stored for less than or equal to 30 calendar days from the date it was collected, the DOS of the test/service must be the date the test/service was performed only if: The test/service is ordered by the patient's physician at least 14 days following the date of the patient's discharge from the hospital; The specimen was collected while the patient was undergoing a hospital surgical procedure; It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted; The results of the test/service do not guide treatment provided during the hospital stay; and The test/service was reasonable and medically necessary for treatment of an illness. If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the DOS of the test/service must be the date the specimen was obtained from storage. This specimen meets the definition of a stored specimen, and as such it is not appropriately billed with DOS January 4, 2022. The claim was incorrectly billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. There is no documentation the specimen was collected directly by the laboratory. If an independent lab bills for services, the place where the sample was taken is shown. POS code 81 is used to describe samples taken by the laboratory directly. An independent laboratory taking a sample in its laboratory shows "81" as place of service. If an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, it uses the code for the inpatient (POS code 21), off campus-outpatient hospital (POS code 19), or on campus-outpatient hospital (POS code 22), respectively. Finally, the claim did not contain the required unique test identifier code required by Medicare.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid due to issues with the dates of service billed, the POS code billed and the omission of the required unique test identifier code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 4, 2022.