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) 81301 and 81194.  
 
You asked the Plan to pay for procedure codes 81455, 81301 and 81194 billed for date of service February 28, 
2023. You say that these services are supported in the medical records. The Plan says that these services were 
not billed in accordance with Medicare guidelines. 
 
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 payment of this service stating that the necessary 
Dex-Z code was not included. However, the Local Coverage Determination cited by the Plan does not apply to 
the state where this test was actually performed. The state in question does not participate in the Molecular 
Diagnostics (MolDX) contractor program. The Plan has not provided a reason for denial of this service which 
is relevant 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) 81301 
and 81194. 
 
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 81301 and 81194 are column II codes to column I code 81455; however, 
81301 and 81194 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 81301 and 81194. Our reviewer says that 
the XU modifier is not supported with these services. Our reviewer found that the record supports that these 
services were included in the primary procedure and were not unusual non-overlapping services. Therefore, the 
use of the XU modifier is not supported, and these codes are not supported for separate reporting or payment. 
 
 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) 81301 and 81194 have not been 
met. Therefore, we decided that the Plan does not have to pay for the services described by procedure code(s) 
81301 and 81194. 
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.