Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 87640-59-90, 87651-90, and 87653-90. We decided that the Plan does 
not have to pay for 87491-90, 87496-90, 87500-90, 87529-90, 87563-90,87591-90, 87641-90, 87661-90 and 
87798-90 (13 units).   
You asked the Plan to pay for practitioner services provided on May 1, 2023, billed with procedure codes 
87491-90, 87496-90, 87500-90, 87529-90, 87563-90,87591-90, 87640-59-90, 87641-90, 87651-90, 87653-90, 
87661-90 and 87798-90 (13 units). 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 87640-59-90, 87651-90, and 87653-90.  
 
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 physician reviewer found that 87640, 87651, and 
87653 are supported. The record states that these tests were performed and were negative. The remainder of the 
codes are not supported, there are no results stating these tests were 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 87640-59-90, 87651-90, and 87653-90.  
 
We also decided that the Plan does not have to pay for 87491-90, 87496-90, 87500-90, 87529-90, 87563-
90,87591-90, 87641-90, 87661-90 and 87798-90 (13 units). 
 
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 physician reviewer found that 87640, 87651, and 
87653 are supported. The record states that these tests were performed and were negative. The remainder of the 
codes are not supported, there are no results stating these tests were 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 87491-90, 87496-90, 87500-90, 87529-90, 87563-90,87591-90, 87641-90, 87661-90 
and 87798-90 (13 units). 
 
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.