Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88342, 88291, 88368, 88369 and 88377 
billed for date of service January 6, 2023.   
You asked the Plan to pay for procedure codes 88342, 88291, 88368, 88369 and 88377. You say that these 
services were necessary and were reported correctly.  The Plan denied your request. The Plan says these 
services are not supported for separate reporting.  
 
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 rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
In this case, we have confirmed that code 88342 is a column II code to column I codes 88184 and 88189; 
however, 88342 was billed with a modifier of -59.  
 
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 88342. Our reviewer says that the criteria for 
coverage have not been met.  Our reviewer found that the laboratory report does not include documentation to 
support a separate distinct service and would not be reported for the same or similar specimens. Therefore, this 
procedure denied correctly as an unbundled service.  
 
We also have confirmed that code 88291 is a column II code to column I codes 81120, 81121, 81218, 81245, 
81246, 81272, 81310 and G0452; however, 88291 was billed with a modifier of -59. 
 
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 88291. Our reviewer says that the criteria for 
coverage have not been met.  Our reviewer found that the laboratory report does not include documentation to 
support a separate and distinct service. Therefore, modifier -59 cannot be verified.  
 
We also have confirmed that code 88368 is a column II code to column I codes 81120; 81121; 81218; 81245; 
81246; 81272; 81310; however, 88368 was billed with a modifier of -59. 
 
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 88368. Our reviewer says that the criteria for 
coverage have not been met.  Our reviewer found that the laboratory report does not include documentation to 
support a separate and distinct service. Therefore, modifier -59 cannot be verified.  
 
We also have confirmed that code 88369 is a column II code to column I codes 81120; 81121; 81218; 81245; 
81246; 81272; 81310; however, 88291 was billed with a modifier of -59. 
 
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 88369. Our reviewer says that the criteria for 
coverage have not been met.  Our reviewer found that the laboratory report does not include documentation to 
support a separate and distinct service. Therefore, modifier -59 cannot be verified.  
 
We also have confirmed that code 88377 is a column II code to column I codes 81120; 81121; 81218; 81245; 
81246; 81272; 81310; however, 88377 was billed with a modifier of -59. 
 
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 88377. Our reviewer says that the criteria for 
coverage have not been met.  Our reviewer found that the laboratory report does not include documentation to 
support a separate and distinct service. Therefore, modifier -59 cannot be verified.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 88342, 88291, 88368, 88369 and 88377 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 88342, 88291, 88368, 88369 and 
88377 billed for date of service January 6, 2023.