Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for 87496, 87498 and 87532. We decided that the Plan does not have to 
pay for 87502.  
 
You asked the Plan to pay for laboratory services (procedure codes 87496, 87498, 87502, and 87532) rendered 
on December 28, 2022.. You say that this should be paid for. The Plan says that the records do not support the 
services billed.  
We decided that the Plan has to pay for 87496, 87498 and 87532.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of the overturned codes are: 
 
CPT 87496: 
 
Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique 
 
CPT 87498: 
 
Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique, includes 
reverse transcription when performed 
 
CPT 87532: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, amplified probe technique 
 
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 these codes. Our reviewer says that these codes are 
supported by the medical records. Cytomegalovirus is not a respiratory virus and is not included in 87633; 
there is no National Correct Coding Initiative (NCCI) edit between these codes. The results show this test was 
performed. Enterovirus is not a respiratory virus and is not included in CPT 87633; there is no NCCI edit 
between these codes. The results show this test was performed. Finally, herpes virus 6 is not a respiratory virus 
and is not included in CPT 87633. There is no NCCI edit between these codes. The results show this test was 
performed. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
87496, 87498 and 87532.  
 
We also decided that the Plan does not have to pay for 87502. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 87502 is "Infectious 
agent detection by nucleic acid (DNA or RNA); 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." 
 
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 87502. Our reviewer says that CPT code 
87502 is not supported. According to CPT and National Correct Coding Initiative (NCCI) rules, this is included 
in the respiratory virus panel and not separately reportable with CPT 87633. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87502 have not been met. Therefore, we decided that the Plan does not have to 
pay for 87502. 
 
 
 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.