Appeal type: Lab
Decision: Partially Favorable

 
You asked the Plan to pay for laboratory testing provided on August 30, 2023. You say that you are appealing 
with supporting records. The Plan says that these codes were not appropriately billed. 
 
We decided that the Plan has to pay for lab tests 87500, 87481, and 87653. 
 
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 87500 is infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, 
enterococcus species van A, van B), amplified probe technique. The CPT Code Manual definition of code 
87481 is infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe 
technique. The CPT Code Manual definition of code 87653 is infectious agent detection by nucleic acid (DNA 
or RNA); Streptococcus, group B, amplified probe technique. 
 
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 item/service at issue. Our reviewer says that these codes 
do meet criteria for payment. Our coding reviewer found there are results showing that these tests were 
performed. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for lab tests 87500, 87481, and 87653.  
 
We also decided that the Plan does not have to pay for lab tests 87801, 87798, and 87641. 
 
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 87801 is infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified 
probe(s) 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 87641 is infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus 
aureus, methicillin resistant, amplified probe technique. 
 
We asked our coding reviewer 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 item/service at issue. Our reviewer says 
that these codes do not meet criteria for payment. Our coding reviewer found there is no documented result or 
evidence that these tests were performed.  
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for lab tests 87801, 87798, and 87641. 
 
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.