Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for 87491, 87625, 87925, 87591, and 87661. We decided that the Plan does 
not have to pay for 87640.  
 
You asked the Plan to pay for procedure codes 87491, 87529, 87591, 87625, 87640, and 87661 rendered on 
February 23, 2023.. You say that you submitted medical records for review. The Plan says that the records do 
not support the services billed. 
 
We decided that the Plan has to pay for 87491, 87625, 87925, 87591, and 87661.  
 
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 definition of the overturned codes is: 
 
CPT 87491: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique 
 
CPT 87529: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique 
 
CPT 87625: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 
only, includes type 45, if performed 
 
CPT 87591: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique 
 
CPT 87661: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, amplified probe technique 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request for these codes. Our reviewer says that these services 
are not supported by the medical records. 
 
The laboratory report includes documentation of Chlamydia, trachmomatis (CPT 87491) with the result - "not 
detected." The service is supported. 
 
The laboratory report includes documentation of human papillomavirus 16 and 18 (CPT 87625), with result 
"not detected." Therefore, the service is supported. 
 
The laboratory report includes documentation of Herpes simplex virus (CPT 87925), with result - "not 
detected." The services are supported. 
 
The laboratory report includes documentation of Neisseria gonorrhoeae (CPT 87591), with result - "not 
detected." Therefore, the services are supported. 
 
The laboratory report includes documentation of Trichomonas vaginalis (CPT 87661), with result - "not detected." Therefore, the services are supported. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
87491, 87625, 87925, 87591, and 87661.  
 
We also decided that the Plan does not have to pay for 87640. 
 
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 definition of CPT 87640 is "nfectious agent 
detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique." 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request for CPT 87640. Our reviewer says that the 
documentation does not support this as a separate service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87640 have not been met. Therefore, we decided that the Plan does not have to 
pay for 87640. 
 
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.