Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 10, 2022.
You asked the Plan to pay for this testing. You say that this testing should be covered by the Plan. The Plan
denied your request. The Plan says the Medicare billing criteria were no met. Maximus overturned the Plans
denial. The Plan requested a reopen and provided additional information. The Plan notes the claim was billed
with a date of service inconsistent with Medicare rules governing laboratory services. The enrollee was an
inpatient at a facility from June 8, 2021, to June 15, 2021. The records submitted show that specimens were
collected on June 8, 2021, by the inpatient hospital. The specimen was received on February 1, 2022, by the
billing provider. The provider stated that the test was ordered February 10, 2022. 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 date of service (DOS) of
the test or service must be the date the test or 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 or 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stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the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 or 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 February 10, 2022. The
claim was also 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, the POS code used is not 81. Medicare billing criteria were not met.
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 had billing errors regarding the dates of service reported for the
testing and the POS code reported for the location of the specimen collection. Medicare rules for coverage of
this testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing
provided to the enrollee on February 10, 2022.