Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pay for  procedure code U0003. We decided that the Plan does not have to pay 
for  procedure codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798, and U0005.  
 
You asked the Plan to pay for  the lab testing billed for date of service September 23, 2022. You say that the 
test is a vital diagnostic tool. The Plan says that the enrollee does not meet the criteria for the panel. 
 
We decided that the Plan has to pay for  procedure code U0003.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The CPT Code Manual definition of code U0003 is infectious agent detection by nucleic acid; 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. 
 
We find that code U0003 is supported in the medical record. The records show that Covid-19 testing was 
ordered, performed, and billed in addition to the respiratory panel. Based on this information, we decided that 
the Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pay for  procedure 
code U0003 billed for date of service September 23, 2022.  
 We also decided that the Plan does not have to pay for  procedure codes 87486, 87496, 87498, 87502, 
87532, 87541, 87581, 87634, 87640, 87798, and U0005. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used.  
 
The CPT Code Manual definition of code U0005 is infectious agent detection by nucleic acid; severe acute 
respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, 
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 looked at the file and the rules. We find that CPT code U0005 is not supported in the medical record. The 
records do not show that the testing was completed within 2 calendar days from the date of specimen 
collection.  

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 87486, 87496, 87498, 87502, 87532, 87541, 
87581, 87634, 87640, 87798, and U0005. 
 
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.