Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on May 8, 2023. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says these are components of a multi-component code and it would be more 
appropriate to use code 81479. 
 
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 87486 is chlamydia pneumoniae, amplified probe 
technique. 
 
The CPT Code Manual definition of code 87502 is influenza virus, for multiple types or sub-types, includes 
multiplex reverse transcription, when performed, and multiplex amplified probe technique, first 2 types or sub-
types.  
The CPT Code Manual definition of code 87503 is influenza virus, for multiple types or sub-types, includes 
multiplex reverse transcription, when performed, and multiplex amplified probe technique, each additional 
influenza virus type or sub-type beyond 2 (List separately in addition to code for primary procedure). 
 
The CPT Code Manual definition of code 87541 is legionella pneumophila, amplified probe technique. 
 
The CPT Code Manual definition of code 87581 is mycoplasma pneumoniae, amplified probe technique. 
 
The CPT Code Manual definition of code 87651 is streptococcus, group A, amplified probe technique. 
 
The CPT Code Manual definition of code 87798 is infectious agent detection, by nucleic acid (DNA or RNA), 
not otherwise specified, amplified probe technique, per organism. 
 
The CPT Code Manual definition of code U0005 is coronavirus diagnostic panel. 
 
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 lab tests. Our reviewer says that these codes do not meet 
criteria for payment. 
 
For code 87486 our reviewer found this procedure would be included in not otherwise specified when 
documented correctly. 
 
For code 87502 our reviewer found the provider reported a not otherwise list code; however, documentation of 
the specific tests being reported with the multiple procedure code. In this case this procedure cannot be 
verified. 
 
For code 87503 our reviewer found the provider reported a not otherwise list code; however, documentation of 
the specific tests being reported with the multiple procedure code. In this case this procedure cannot be 
verified. 
 
For code 87541 our reviewer found the provider reported a not otherwise list code; however, documentation of 
the specific tests being reported with the multiple procedure code. In this case this procedure cannot be 
verified. 
 
For code 87581 our reviewer found the provider reported a not otherwise list code; however, documentation of 
the specific tests being reported with the multiple procedure code. In this case this procedure cannot be 
verified. 
 
For code 87651 our reviewer found this procedure would be included in not otherwise specified when 
documented correctly. 
 
For code 87798 our reviewer found the documentation includes a physician order for COVID-19 respiratory 
panel. The laboratory report documents multiple tests performed; however, code 87798 describes not 
otherwise specified. Medical records do not include documentation of specific codes being billed with this 
procedure code and therefore cannot be verified. 
 
For code U0005 our reviewer found the provider reported a not otherwise list code; however, documentation of 
the specific tests being reported with the multiple procedure code. In this case this procedure cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided on May 8, 2023.