Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for one unit of code 87801 and procedure code 87481-XU. We decided 
that the Plan does not have to pay for two additional units of code 87801 and procedure codes 87653 and 
87798.  
 
You asked the Plan to pay for procedure codes 87481, 87653, 87798 and 87801 billed for date of service 
November 30, 2022. You say that these services were necessary and were reported appropriately. The Plan says 
that the payment for codes 87481 and 87653 would be included in the payment for code 87801. Although 
modifiers were used with these services, the records do not support the use of these modifiers. In addition, the 
records are unclear as to which services are being reported with code 87798, and the records do not support 3 
units of 87801. 
 
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 column II codes to column I code 87801; 
however, 87481 and 87653 were each billed with a modifier. 
 
We decided that the Plan has to pay for one unit of code 87801 and procedure code 87481-XU.  
 
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 one unit of code 87801 and procedure code 87481-XU. Our 
reviewer says that these services are supported in the medical record. Our reviewer found that the description 
for code 87801 includes multiple organisms; the results support one unit of code 87801. In addition, code 
87481 with modifier XU is supported. The record shows results for candida albicans. According to CPT coding 
instructions for 87801, when codes exist for specific organisms in the 87471-87660 range they should be 
reported separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of one unit of code 87801 and procedure code 87481-XU have been met. 
Therefore, we decided that the Plan has to pay for one unit of code 87801 and procedure code 87481-XU.  
 
We also decided that the Plan does not have to pay for two additional units of code 87801 and procedure 
codes 87653 and 87798. 
 
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 two additional units of code 87801 and procedure codes 
87653 and 87798. Our reviewer says that these items/services are not supported in the medical record as 
reported. Our physician reviewer found only one unit of code 87801 is supported as this code reports multiple 
organisms. Code 87798 is not supported; the not otherwise specified organisms are not identified in the results. 
It cannot be verified that these organisms are not already reported with a different CPT code. In addition, code 
87653 is not supported. The record does not contain an order or results for infectious agent testing for group B 
streptococcus; there is no evidence 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 two additional units of code 87801 and procedure codes 87653 and 87798 have 
not been met. Therefore, we decided that the Plan does not have to pay for two additional units of code 87801 
and procedure codes 87653 and 87798. 
 
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.