Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87486, 87498, 87502, 87503, 87581, 
87631, 87634 and 87798) provided on November 9, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says this testing should be billed with code 81479 and is not supported as multiple 
codes. 
 
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 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 laboratory services. Our reviewer found Code 87486, the 
documentation submitted was reviewed, and does meet criteria. The laboratory report includes documentation 
of chlamydia pneumoniae, amplified probe technique. This procedure would not be considered molecular 
pathology, and 81479 would be inappropriate to report for this procedure. Code 87498, the documentation 
submitted was reviewed and does not meet criteria. The laboratory report does not include documentation of 
enterovirus testing, and therefore, cannot be verified. Our reviewer was unable to cite the report, as this test 
was not found in the medical record. Code 87502, the documentation submitted was reviewed and does not 
meet criteria. The laboratory report includes documentation to support influenza virus; however, this procedure 
would be included in CPT 87631. Therefore, modifier 59 cannot be verified. Code 87503, the documentation 
submitted was reviewed and does not meet criteria. The laboratory report includes documentation to support 
influenza virus: however, this procedure would be included in CPT 87631. Therefore, modifier 59 cannot be 
verified. Code 87581, the documentation submitted was reviewed and does meet criteria. The laboratory report 
includes documentation of mycoplasma pneumoniae, amplified probe technique. This procedure would not be 
considered molecular pathology, and code 81479 would be inappropriate to report for this procedure. The code 
is documented, but it is not separately payable from the main panel code. Code 87631, the documentation 
submitted was reviewed and does meet criteria. The laboratory report includes documentation of respiratory 
virus. This procedure would not be considered molecular pathology, and 81479 would be inappropriate to 
report for this procedure. The code is documented, but it is not separately payable from the main panel code. 
Code 87634, the documentation submitted was reviewed and does meet criteria. The laboratory report includes 
documentation of, respiratory synctial virus. This procedure would not be considered molecular pathology, and 
code 81479 would be inappropriate to report for this procedure. The code is documented, but it is not 
separately payable from the main panel code. Code 87798, the documentation submitted was reviewed and 
does meet criteria. The laboratory report includes documentation of infectious agent detection by nucleic acid 
(DNA or RNA), not otherwise specified; amplified probe technique. This procedure would not be considered 
molecular pathology, and code 81479 would be inappropriate to report for this procedure. The code is 
documented, but it is not separately payable from the main panel code. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (87486, 87498, 87502, 87503, 87581, 87631, 87634 and 
87798) provided on November 9, 2022.