Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure codes 87498, 87502, 87634, 
87798, U0003, and U0005) rendered on February 8, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the coding is not supported. 
 
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 the denied codes is: 
 
CPT 87498: 
 
Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique, includes reverse transcription when performed 
 
CPT 87502: 
 
Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, first 2 
types or sub-types 
 
CPT 87634: 
 
Infectious agent detection by nucleic acid (DNA or RNA); respiratory syncytial virus, amplified probe 
technique 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
Healthcare Common Procedure Coding System (HCPCS) U0003: 
 
Infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-
cov-2) (coronavirus disease [covid-19]), amplified probe technique, making use of high throughput 
technologies as described by cms-2020-01-r 
 
HCPCS U0005: 
 
Infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-
cov-2) (coronavirus disease [covid-19]), amplified probe technique, cdc or non-cdc, making use of high 
throughput technologies, completed within 2 calendar days from date of specimen collection (list separately in 
addition to either hcpcs code u0003 or u0004) as described by cms-2020-01-r2 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provider reported the 
procedure codes 87498, 87502 and 87634 with modifier 59, which indicates a distinct procedural service, to 
bypass the edit. However, the laboratory report does not include any documentation to verify these services a 
distinct procedural service. These codes and modifier 59 cannot be verified. 
 
In terms of CPT 87798, the medical record does not include documentation of the procedures reported with 
CPT 87798, which represents a "not otherwise specified" code. Therefore, this procedure cannot be verified. 
 
Finally, the laboratory report does not support the separate billing of U0003 and U0005, as they are inclusive to 
the paid CPT 87633 - respiratory virus, multiple types or subtypes.  
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services (procedure codes 87498, 87502, 87634, 87798, U0003, and U0005) 
rendered on February 8, 2023.