Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for 87801. We decided that the Plan does not have to pay for 87481, 
87653, and 87798.  
 
You asked the Plan to pay for procedure codes 87481, 87653, 87798, and 87801 rendered on February 23, 
2023.. 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 87801.  
 
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 8801 is "Infectious agent 
detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) 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 CPT 87801. Our reviewer says that the laboratory 
report describes that multiple organisms were tested with amplified probe technique. Therefore, CPT 87801 is 
supported and verified. 
 
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 
87801.  Therefore, we decided that the Plan has to pay for 87801.  
 
We also decided that the Plan does not have to pay for 87481, 87653, and 87798. 
 
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 rest of the codes is: 
 
CPT 87481: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique 
 
CPT 87653: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
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 the laboratory 
report does not include any documentation to support the use of modifier XU - unusual non-overlapping 
service - for these codes. The procedures were performed with the same method. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87481, 87653, and 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for 87481, 87653, and 87798. Therefore, we decided that the Plan does not have to 
pay for 87481, 87653, and 87798. 
 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.