Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 87481 and 87640. We decided that the Plan does not 
have to pay for procedure codes 87486, 87498, and 87641, 87502, 87541, and 87581.  
 
You asked the Plan to pay for practitioner services provided on May 11, 2023, billed with procedure codes 
87481, 87486, 87498-59, 87502-59, 87541, 87581, 87640-59, 87641 and 87651. You say that the claim is 
billed correctly and should be paid. The Plan says that documentation does not support the billed codes. 
 
We decided that the Plan has to pay for procedure codes 87481 and 87640.  
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed. 
 
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 documentation partially supports the billed codes. Our coding reviewer found that 87481 is supported. The 
record states that candida species were tested for and not detected. 87486 is not supported. There is no evidence 
in the record that a test to detect chlamydia pneumoniae was performed. 87498 is not supported. There is no 
evidence in the record that a test to detect enterovirus was performed. There is a more appropriate way to report 
the tests 87502, 87541, and 87581. According to CPT rules, these can be billed as a panel and should not be 
unbundled. 87640 is supported. The record states that this test was performed. 87641 is not supported. The 
record does not contain results confirming that this test was 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 the item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for procedure codes 87481 and 87640.  
 
We also decided that the Plan does not have to pay for procedure codes 87486, 87498, and 87641, 87502, 
87541, and 87581. 
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed. 
 
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 documentation partially supports the billed codes. Our coding reviewer found that 87481 is supported. The 
record states that candida species were tested for and not detected. 87486 is not supported. There is no evidence 
in the record that a test to detect chlamydia pneumoniae was performed. 87498 is not supported. There is no 
evidence in the record that a test to detect enterovirus was performed. There is a more appropriate way to report 
the tests 87502, 87541, and 87581. According to CPT rules, these can be billed as a panel and should not be 
unbundled. 87640 is supported. The record states that this test was performed. 87641 is not supported. The 
record does not contain results confirming that this test was 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 the item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 87486, 87498, and 87641, 87502, 87541, and 87581. 
 
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.