Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 81455. We decided that the 
Plan does not have to pay for the services described by procedure code(s) 81194 and 81301.  
 
You asked the Plan to pay for procedure codes 81455, 81194 and 81301 billed for date of service January 25, 
2023. You say that these services were necessary and are supported as billed. The Plan says that these services 
were not reported in accordance with Medicare rules. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 81455.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan denied this service stating that it is missing a required 
Dex-Z code. However, the Plan cited a Local Coverage Determination (LCD) which does not apply to the state 
where this test was actually performed. The state in question is not a state which participates in the Molecular 
Diagnostics (MolDX) contractor program. There is no similar LCD which applies to this state. The Dex-Z code 
is a requirement of the MolDX contractor, and therefore does not apply in this case. The Plan has not provided 
a relevant reason for denial in this case. Therefore, we decided that the Plan has to pay for the services 
described by procedure code(s) 81455.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 81194 
and 81301. 
 
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 81194 and 81301 are column II codes to column I code 81455; 
however, codes 81194 and 81301 were each billed with a modifier.  
 
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 procedure codes 81194 and 81301. Our reviewer says that 
the record does not support the use of the XU modifier for these codes. Our reviewer found that these codes are 
included in code 81455. The record does not support that they were separate and non-overlapping tests. 
Modifier XU is not 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 described by procedure code(s) 81194 and 81301 have not been met. Therefore, we decided that the Plan does not have to pay for the services described by procedure code(s) 
81194 and 81301. 
 
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.