Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 83631 and 82656. We decided that the Plan does not 
have to pay for procedure codes 83520, 87177, 87209, 82274, 87798, and 82705.  
 
You asked the Plan to pay for the lab testing billed for date of service April 12, 2023. The Plan says that the 
billed codes are not supported. 
 
We decided that the Plan has to pay for procedure codes 83631 and 82656.  
 
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 83631 is lactoferrin, fecal; quantitative. The definition of 
code 82656 is elastase, pancreatic (EL-1), fecal; qualitative or semi-quantitative. We find that CPT codes 
83631 and 92656 are supported in the medical record. The lab requisition does show that the services were 
ordered, and the results do include these tests. 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 83631 and 82656 
billed for date of service April 12, 2023.  
 
We also decided that the Plan does not have to pay for procedure codes 83520, 87177, 87209, 82274, 
87798, and 82705. 
 
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 83520 immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. The definition of code 87798 
is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. The definition of code 87177 is ova and parasites, direct smears, concentration and 
identification. The definition of code 87209 is smear, primary source with interpretation; complex special stain 
(e.g., trichrome, iron hemotoxylin) for ova and parasites. The definition of code 82274 is blood, occult, by fecal 
hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations. The definition 
of code 87205 is smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell 
types. 
 
We find that CPT codes 83520, 87177, 87209, 82274, 87798, and 82705 are not supported in the medical 
record. The records do not show that these tests were ordered or performed. The documentation does not 
specify which organisms/specimens are associated with the codes not otherwise specified. 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 83520, 87177, 87209, 82274, 87798, and 82705 billed for date 
of service April 12, 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.