Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for 83520. We decided that the Plan does not have to pay for 87338 and 
87998.  
 
You asked the Plan to pay for laboratory services (procedure codes 83520, 87338, and 87798) rendered on 
April 25, 2023.. You say that this should be paid for. The Plan says that the records do not support the services 
billed. 
 
We decided that the Plan has to pay for 83520.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 83520 is "Immunoassay 
for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise 
specified." 
 
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 83520. Our reviewer says that the medical 
record includes specific procedures billed with this procedure code, which include Anti-TTG, Fecal by Elisa; 
Anti-Gliadin, Fecal by ELISA; Bile Acids, Fecal by Elisa; Zonulin, Fecal by Elisa.  
 
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 
83520.  
 
We also decided that the Plan does not have to pay for 87338 and 87998. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of the upheld codes is: 
 
CPT 87338: 
 
Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked 
immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), 
qualitative or semiquantitative; Helicobacter pylori, stool 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
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 these codes. Our reviewer says that the laboratory 
report includes documentation of these procedures. However, another infectious agent detection procedure was 
reported. Therefore, there is a more appropriate code that should be reported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87338 and 87998 have not been met. Therefore, we decided that the Plan does 
not have to pay for 87338 and 87998. 
 
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.