Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for 87482. We decided that the Plan does not have to pay for 87799, 
87552, 87652, and 87661.  
 
You asked the Plan to pay for laboratory services (procedure code 87799, 87482, 87552, 87652, and 87661) 
performed on June 26, 2023. You say that this should be paid for. The Plan says that the codes are not 
supported as there are no results. The CPT code manual definition of the denied codes is: 
 
CPT 87799:   
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; quantification, each 
organism 
 
CPT 87482: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Candida species, quantification 
 
CPT 87552: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, quantification 
 
CPT 87652: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification 
 
CPT 87661: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, amplified probe technique 
 
We decided that the Plan has to pay for 87482.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 87799, 87552, 87652, and 87661. Our 
physician reviewer found that in terms of CPT 87799, the provided records do not clarify which pathogens 
were "not otherwise specified." The provided records do not document any testing for CPT 87552, 87652, and 
87661. 
 
We looked at this physician'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 87482.  
 
We also decided that the Plan does not have to pay for 87799, 87552, 87652, 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. 
 
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 87482. Our physician reviewer found that the 
provided records do document this code, as page 3 of the laboratory report indicates multiple Candida species 
were tested and not detected. This is the only code that was documented to be tested in the records. 
 
We looked at this physician'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 87799, 87552, 87652, and 87661. 
 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.