Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 87801 x2 and 87500 x1. We decided that the Plan 
does not have to pay for procedure codes 87150 x2 and 87500 x1.  
 
You asked the Plan to pay for procedure codes 87150, 87801, and 87500 provided on March 27, 2023. You say 
that you would like the Plan to reconsider their denial of payment. The Plan says that the services are not 
supported. 
 
We decided that the Plan has to pay for procedure codes 87801 x2 and 87500 x1.  
 
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 87801 is Infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. The definition of code 87500 is Infectious agent 
detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), 
amplified probe technique. 
 
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 codes 87801 x2 and 87500 x1. 
Our reviewer says that the medical records support two units of procedure code 87801 and one unit of 
procedure code 87500. Our physician reviewer found this case pertains to lab testing done for an enrollee with 
a history of chronic pain. Based on the documentation: For 87801, documentation supports two units were 
identified: Citrobacter freundi/braakii and Enterococcus spp. For 87500, only one unit is supported 
(vancomycin testing for enterococcus).  
 
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 x2 and 87500 x1 have been met. Therefore, we decided 
that the Plan has to pay for procedure codes 87801 x2 and 87500 x1.  
 
We also decided that the Plan does not have to pay for procedure codes 87150 x2 and 87500 x1. 
 
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 87150 is Culture, typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed. The definition 
of code 87500 is Infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, 
enterococcus species van A, van B), amplified probe technique. 
 
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 codes 87150 x2 and 87500 x1. 
Our reviewer says that the medical records do not support two units of procedure code 87150 and the 
remaining unit of procedure code 87500. Our physician reviewer found this case pertains to lab testing done for 
an enrollee with a history of chronic pain. Based on the documentation: For 87150, documentation does not 
support the billing of 2 units. For 87500, only one unit is supported (vancomycin testing for enterococcus).  
 
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 87150 x2 and 87500 x1 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87150 x2 and 87500 x1. 
 
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.