Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 87150. We decided that the Plan does not have to pay 
for procedure codes 87801 and 87500.  
 
You asked the Plan to pay for procedure codes 87801, 87500, and 87150 provided on January 16, 2023. You 
say that the medical records support the billing of codes 87801, 87500-XU, and 87150-XU. The Plan says that 
the medical records do not support the billing of codes 87801, 87500-XU, and 87150-XU. 
 
We decided that the Plan has to pay for procedure code 87150.  
 
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, we have confirmed that code 87150 is a column II code to column I code 87500; however, 87150 
was billed with a modifier. 
 
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 to pay for procedure code 87150-XU. Our reviewer 
says that the medical records support the billing of procedure code 87150-XU. Our physician reviewer found 
the laboratory report supports the procedure billed with the XU modifier as it would not be inclusive to the 
unpaid column I code. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87150 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 87150.  
 
We also decided that the Plan does not have to pay for procedure codes 87801 and 87500. 
 
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 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 payment of procedure codes 87801 and 87500-XU. 
Our reviewer says that the medical records do not support the billing of procedure codes 87801 and 87500-XU. 
Our physician reviewer found that procedure code 87801 is not supported as the laboratory report describes 
multiple organisms tested, however includes insufficient documentation to confirm laboratory tests reported 
with this procedure code, and therefore cannot be verified. 
 
Procedure code 87500 is not supported as the healthcare provider reported the procedure code with appended 
modifier XU Unusual non-overlapping service to bypass NCCI Edit with CPT 87150, however report does not 
include documentation to support the appended modifier, and therefore cannot be verified.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87801 and 87500 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87801 and 87500. 
 
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.