Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) procedure code 81445. We 
decided that the Plan does not have to pay for the services described by procedure code(s) procedure code 
88381.  You asked the Plan to pay for procedure codes 81445 and 88381 billed for date of service October 18, 2022. 
You say that these services were necessary and are supported as billed. The Plan says that code 88381 is not 
supported in the medical record, and code 81445 is missing the necessary Dex-Z code on the claim. 
 
We decided that the Plan has to pay for the services described by procedure code(s) procedure code 
81445.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Local Coverage Article cited by the Plan does not apply to the 
state where this test was actually performed. The state where the laboratory services were rendered is not a 
Molecular Diagnostics (MolDX) contractor state and does not participate in the MolDX program. Therefore, 
these rules do not apply. The Plan has provided no other denial rationale for this service. Therefore, we decided 
that the Plan has to pay for the services described by procedure code(s) procedure code 81445.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
procedure code 88381. 
 
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 88381 is microdissection (i.e., sample preparation of microscopically identified target); manual. 
 
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 883381. Our reviewer says that this code is 
not supported in the records provided. Our reviewer found that the laboratory report does not include sufficient 
documentation to support procedure code reported. For CPT 88381, a clinician, typically a pathologist, 
performs a manual microdissection of a patient's specimen, such as a biopsy or tissue preserved from a 
previous case. This procedure was not found in medical record. 
 
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) procedure code 88381 have not 
been met. Therefore, we decided that the Plan does not have to pay for the services described by procedure 
code(s) procedure code 88381. 
 
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.