Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87481-59, 87491-59, 87500, 87563-
59, 87640-59, 87641, 87653-59, 87798-59) provided June 15, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 the definition of code 87481-59 is infectious agent 
detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique. The definition of code 
87491-59 is infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified 
probe technique. The definition of code 87500 is infectious agent detection by nucleic acid (DNA or RNA); 
Chlamydia trachomatis, amplified probe technique. The definition of code 87563-59 infectious agent detection 
by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique. The definition of code 
87640-59 is infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe 
technique. The definition of code 87641 is infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, methicillin resistant, amplified probe technique. The definition of code 87653-59 
infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique. 
The definition of code 87798-59 infectious agent detection by nucleic acid (DNA or RNA), not otherwise 
specified; amplified probe technique, each organism. 
 
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 the laboratory services. Our reviewer found for code 87481, 
the documentation submitted was reviewed and does not meet criteria. Laboratory report includes multiple 
infectious agent detection testing, and in this case, should be reported with a panel procedure code. Therefore, 
this procedure code and appended modifier 59 distinct procedural service cannot be verified. 
 
For code 87491, the documentation submitted was reviewed and does not meet criteria. Laboratory report 
includes multiple infectious agent detection testing, and in this case, should be reported with a panel procedure 
code. Therefore, this procedure code and appended modifier 59 distinct procedural service cannot be verified. 
 
For code 87500, the documentation submitted was reviewed and does not meet criteria. Laboratory report 
includes multiple infectious agent detection testing, and in this case, should be reported with a panel procedure 
code. Therefore, this procedure code and appended modifier 59 distinct procedural service cannot be verified. 
 
For code 87563, the documentation submitted was reviewed and does not meet criteria. Laboratory report 
includes multiple infectious agent detection testing, and in this case, should be reported with a panel procedure 
code. Therefore, this procedure code and appended modifier 59 distinct procedural service cannot be verified. 
 
For code 87640, the documentation submitted was reviewed and does not meet criteria. Laboratory report 
includes multiple infectious agent detection testing, and in this case, should be reported with a panel procedure 
code. Therefore, this procedure code and appended modifier 59 distinct procedural service cannot be verified. 
 
For code 87641, the documentation submitted was reviewed and does not meet criteria. Laboratory report 
includes multiple infectious agent detection testing, and in this case, should be reported with a panel procedure 
code. Therefore, this procedure code and appended modifier 59 distinct procedural service cannot be verified. 
 
For code 87653, the documentation submitted was reviewed and does not meet criteria. Laboratory report 
includes multiple infectious agent detection testing, and in this case, should be reported with a panel procedure 
code. Therefore, this procedure code and appended modifier 59 distinct procedural service cannot be verified. 
 
For code 87798, the documentation submitted was reviewed and does not meet criteria. Procedure code 
represents, "not otherwise specified", and in this case medical record does not include documentation to 
support the procedure codes reported with CPT 87798, and therefore 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 the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (87481-59, 87491-59, 87500, 87563-59, 87640-59, 87641, 
87653-59, 87798-59) provided June 15, 2023.