Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes U0003 and U0005. We decided that the Plan does not 
have to pay for procedure codes 87502, 87498, 87541, 87486, 87581, 87640, 87641, and 87651.  
 
You asked the Plan to pay for the lab testing billed for date of service April 20, 2023. You say that the test 
provides valuable information for physicians. The Plan says that one code must be submitted for the panel. 
 
We decided that the Plan has to pay for procedure codes U0003 and U0005.  
 
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 CPT Code Manual definition of code U0003 is infectious agent detection by nucleic acid; severe acute 
respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [Covid-19]), amplified probe 
technique, making use of high throughput technologies as described by CMS-2020-01-R. 
 
The CPT Code Manual definition of code U0005 is infectious agent detection by nucleic acid; severe acute 
respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [covid-19]), amplified probe 
technique, making use of high throughput technologies, completed within 2 calendar days from date of 
specimen collection (list separately in addition to either code U0003 or U0004) as described by CMS-2020-01-
R2. 
 
We find that CPT codes U0003 and U0005 are supported in the medical record. The lab test results show that 
Covid 19 testing was provided apart from the respiratory panel. The records also show that the testing was 
completed within 2 calendar days from the date of specimen collection. Based on this information, we decided 
that Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pay for procedure 
codes U0003 and U0005 billed for date of service April 20, 2023.  We also decided that the Plan does not have to pay for procedure codes 87502, 87498, 87541, 87486, 
87581, 87640, 87641, and 87651. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
The lab records show that a Covid-19 respiratory panel was provided. We looked at the file and Medicare rules. 
This NGS panel was not billed with a single code as required. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87502, 87498, 87541, 87486, 87581, 87640, 87641, and 87651 billed for date of service April 
20, 2023. 
 
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.