Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 83520 and 87798. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 82705.  
 
You asked the Plan to pay for procedure codes 83520 (x5), 87798 and 82705 billed for date of service March 
16, 2023. You say that these services are supported as billed. The Plan says that these services are not 
supported in the records provided. 
 
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 decided that the Plan has to pay for the services described by procedure code(s) 83520 and 87798.  
 
In this case, the CPT Code Manual definition of code 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. The CPT Code Manual 
definition of code 87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified, 
amplified probe technique, each organism. 
 
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 procedure codes 83520 and 87798. Our reviewer says that 
these codes are supported in the records provided. Our reviewer found that the procedure report lists the 
procedures reported, as well as the results for code 83520. The provider used code 87798 to report Listeria 
monocytogenes, Fecal by Real-Time PCR (polymerase chain reaction), which has a documented result. A more 
specific code was not found to support the test performed, and therefore, this procedure would be appropriate to 
report.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 83520 and 87798 have been met. Therefore, we decided that the Plan has 
to pay for the services described by procedure code(s) 83520 and 87798.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
82705. 
 
In this case, the CPT Code Manual definition of code 82705 is fat or lipids, feces; qualitative. 
 
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 procedure code 82705. Our reviewer says that this code is 
not supported in the records provided. Our reviewer found that the laboratory report documents, fecal fat, 
semi-quantitative  neutral. In this case, there would be a more appropriate code for the service provided. 
 
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 services described by procedure code(s) 82705 have not been met. 
Therefore, we decided that the Plan does not have to pay for the services described by procedure code(s) 
82705. 
 
 
 
 
 
 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.