Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, and 87798 
rendered on January 27, 2023.   

You asked the Plan to pay for the services. You say that this should be paid for.  The Plan denied your request. 
The Plan says the records do not support the services billed.  
 
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, the CPT Code Manual definition of code 87150 is culture, typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed. The definition 
of 87481 is infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe 
technique. The definition of 87641 is infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, methicillin resistant, amplified probe technique. The definition of 87653 is infectious 
agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique. The 
definition of 87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; 
amplified probe technique, each organism. 
 
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 the services. Our reviewer found for code 87150, the 
documentation submitted was reviewed and does not meet criteria. The provider reported procedure code with 
appended modifier XU Unusual non-overlapping service to bypass NCCI Edit; however, the laboratory report 
does not include documentation to support procedure coded, and modifier. Therefore, this procedure would be 
included in code 87801 which includes multiple organism, amplified probe technique. For code 87481, the 
documentation submitted was reviewed and does not meet criteria. The provider reported procedure code with 
appended modifier XU Unusual non-overlapping service to bypass NCCI Edit; however, the laboratory report 
does not include documentation to support procedure coded, and modifier. Therefore, this procedure would be 
included in code 87801, which includes multiple organism, amplified probe technique. For code 87641, the 
documentation submitted was reviewed and does not meet criteria. The provider reported procedure code with 
appended modifier XU Unusual non-overlapping service to bypass NCCI Edit; however, the laboratory report 
does not include documentation to support procedure coded, and modifier. Therefore, this procedure would be 
included in code 87801 which includes multiple organism, amplified probe technique. For code 87653, the 
documentation submitted was reviewed and does not meet criteria. The provider reported procedure code with 
appended modifier XU Unusual non-overlapping service to bypass NCCI Edit; however, the laboratory report 
does not include documentation to support procedure coded, and modifier. Therefore, this procedure would be 
included in code 87801 which includes multiple organism, amplified probe technique. For code 87798, the 
documentation submitted was reviewed and does not meet criteria. The provider reported procedure code with 
appended modifier XU Unusual non-overlapping service to bypass NCCI Edit; however, the laboratory report 
does not include documentation to support procedure coded, and modifier. Therefore, this procedure would be 
included in code 87801, which includes multiple organism, amplified probe technique. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 87150, 87481, 87641, 87653, and 87798 rendered on January 27, 2023.