Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes U0003 and U0005. We decided that the Plan does not 
have to pay for procedure codes 87498, 87502, 87634, 87081, 87186, and 87798.  
 
You asked the Plan to pay for the lab testing billed for date of service March 16, 2023. You say that the test 
will aid in the diagnosis of the enrollee. The Plan says that the codes are not payable as billed. 
 
We decided that the Plan has to pay for procedure codes U0003 and U0005.  
 
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 U0003 is Infectious agent detection by nucleic acid; 
severe acute respiratory syndrome coronavirus 2, amplified probe technique. The definition of code U0005 is 
Infectious agent detection by nucleic acid; severe acute respiratory syndrome coronavirus 2, amplified probe 
technique, completed within 2 calendar days from date of specimen collection (list separately in addition to 
either code U0003 or U0004) as described by CMS-2020-01-R2. 
 
We find that CPT code U0003 is supported in the medical record. The lab reports shows that Covid 19 testing 
was provided. We have confirmed that code U0005 is an add-on code that has been billed with an appropriate 
primary procedure code. The records also confirm that the testing was completed within 2 calendar days from 
the date the specimen was collected. Based on this information, we decided that Medicare rules for coverage 
have been met. Therefore, we decided that the Plan has to pay for procedure codes U0003 and U0005 billed for 
date of service March 16, 2023.  
 
We also decided that the Plan does not have to pay for procedure codes 87498, 87502, 87634, 87081, 
87186, and 87798. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. In this case, the respiratory panel, billed with codes 87498, 87502, and 
87634 was not billed with a single code as required. Based on this information, we decided that Medicare rules 
for coverage have not been met. 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 87081 is culture, presumptive, pathogenic organisms, 
screening only. We find that CPT code 87081 is not supported in the medical record. Specifically, the records 
do not support that 2 units of a culture screening was provided.  
 
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 find that CPT code 87798 is not 
supported. The records do not show that 7 organisms associated with this code was tested. 
 
The CPT Code Manual Definition of code 87186 is susceptibility studies, antimicrobial agent; microdilution or 
agar dilution (minimum inhibitory concentration [MIC] or breakpoint), each multi-antimicrobial, per plate. We 
find that CPT code 87186 is not supported. The results of susceptibility testing are interpreted as S (sensitive), I 
(intermediate), or R (resistant) followed by the minimum inhibitory concentration (MIC) in microgram per 
milliliter (ug/mL) units. The records do not document this interpretation.  
 
We looked at the file and the rules. Based on this information, we decided that Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87498, 87502, 
87634, 87081, 87186, and 87798 billed for date of service March 16, 2023. 
 
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.