Appeal type: Outpatient Mental Health
Decision: Partially Favorable

 
We decided that the Plan has to pay for G0481. We decided that the Plan does not have to pay for 96138.  
 
You asked the Plan to pay for procedure codes 96138 and G0481 provided to the enrollee on September 7, 
2022.. You say that you submitted medical records for review. The Plan says that the denied codes remain not 
supported. 
 
We decided that the Plan has to pay for G0481.  
 
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 G0481 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; 8-14 
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 G0481. Our reviewer says that the laboratory report 
includes documentation of both tests in the physician documentation. 
 
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 
G0481.  
 
We also decided that the Plan does not have to pay for 96138. 
 
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 96138 is "Psychological or neuropsychological test 
administration and scoring by technician, two or more tests, any method; first 30 minutes." 
 
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 96138. Our reviewer says that the medical 
record does not include enough documentation to verify a psychological or neuropsycholgical test 
administration and scoring by technician, two or more tests, any method; first 30 minutes. The documentation 
describes that this procedure was performed during evaluation and management service, which would include 
testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 96138 have not been met. Therefore, we decided that the Plan does not have to 
pay for 96138. 
 
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.