Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 87801. We decided that the 
Plan does not have to pay for the services described by procedure code(s) 87481 and 87653.  
 
You asked the Plan to pay for procedure codes 87801, 87481 and 87653 billed for date of service December 14, 
2022. You say that these services were reported appropriately and are supported in the medical record. The 
Plan says that these services are not supported for separate payment. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 87801.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 87801.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 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, we have confirmed that codes 87481 and 87653 are both column II codes to column I code 87801. 
Code 87481 has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, 
Medicare billing criteria have not been met for code 87481. However, code 87653 was billed with a modifier.  
 
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 87653. Our reviewer says that the use of the 
XU modifier is not supported with this code. Our reviewer found that the laboratory report does not include 
documentation to support how Streptococcus, group B is an unusual non-overlapping service from code 87801, 
which includes multiple organisms. Therefore, this procedure and modifier 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 87481 and 87653 have not been met. Therefore, we decided 
that the Plan does not have to pay for the services described by procedure code(s) 87481 and 87653. 
 
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.