Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on May 9, 2023. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says there is a more appropriate panel code that should be used, 87507. 
 
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 87486 is infectious agent detection by nucleic acid (DNA 
or RNA); Chlamydia pneumoniae, amplified probe technique. The CPT Code Manual definition of code 87498 
is infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique, includes 
reverse transcription when performed. The CPT Code Manual definition of code 87502 is 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. The 
CPT Code Manual definition of code 87581 is infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, amplified probe technique. The CPT Code Manual definition of code 87640 is 
infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique. 
The CPT Code Manual definition of code 87651 is infectious agent detection by nucleic acid (DNA or RNA); 
Streptococcus, group A, amplified probe technique. 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. The CPT Code Manual definition of code U0003 is 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. The 
CPT Code Manual definition of code U0005 is 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 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 lab tests. Our reviewer says that these codes are not 
supported for payment. Our reviewer found coding rules require a panel code when all tests in a panel are 
performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided on May 9, 2023.