Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 87900. We decided that the Plan does not have to pay 
for procedure codes 87652 and 87899.  

You asked the Plan to pay for procedure codes 87652, 87899 and 87900 billed for date of service November 9, 
2022. You say that these services were necessary and are supported in the medical record. The Plan says that 
these codes are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We decided that the Plan has to pay for procedure code 87900.  
 
In this case, the CPT Code Manual definition of code 87900 is infectious agent drug susceptibility phenotype 
prediction using regularly updated genotypic bioinformatics. 
 
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 code 87900. Our reviewer says that this code is 
supported in the records provided. Our reviewer found that no guideline was found for further description of 
procedure code to include details used by the Plan. The description further explains the medical records must 
contain "quantitative prediction of drug susceptibility phenotype." Therefore, the Plan's denial of this code 
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 procedure code 87900 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 87900.  
 
We also decided that the Plan does not have to pay for procedure codes 87652 and 87899. 
 
In this case, the CPT Code Manual definition of code 87652 is infectious agent detection by nucleic acid (DNA 
or RNA); Streptococcus, group A, quantification. The CPT Code Manual definition of code 87899 is infectious 
agent antigen detection by immunoassay with direct optical (i.e., visual) observation; not otherwise specified. 
 
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 87652 and 87899. Our reviewer says that 
these codes are not supported in the records provided. Our reviewer found that for CPT code 87652, the lab 
analyst performs a test to quantify infection with Streptococcus, group A, using nucleic acid probe technique. 
This procedure was not found in medical record and therefore cannot be verified. For CPT code 87899, the lab 
analyst performs the technical lab test to analyze for an infectious agent by immunoassay with direct optical, 
meaning visual, observation. This procedure was not found in medical record, 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 procedure codes 87652 and 87899 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87652 and 87899. 
 
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.