Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99204. We decided that the 
Plan does not have to pay for the services described by procedure code(s) 82270.  
 You asked the Plan to pay for procedure codes 99204 and 82270 provided on September 7, 2023. You say that 
you would like the Plan to reconsider their denial of payment. The Plan says that the services are not supported. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 99204.  
 
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 99204 is Office or other outpatient visit for the evaluation and management of a new patient, which 
requires a medically appropriate history and/or examination and moderate level of medical decision making. 
When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.  
 
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 99204. Our reviewer says that the medical 
records support the billing of procedure code 99204. Our reviewer found the history and exam were appropriate 
and decision making was moderate. Decision-making addressed two unrelated, yet important problems 
(testosterone therapy and change in creatinine) and the assessment and plan were reasonable and 
thoughtfully/thoroughly described. Time spent was also documented. 
 
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 99204 have been met. Therefore, we decided that the Plan has 
to pay for the services described by procedure code(s) 99204.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
82270. 
 
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 82270 is Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected 
specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or 
single triple card for consecutive collection). 
 
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 82270. Our reviewer says that the medical 
records do not support the billing of procedure code 82270. It appears that it was a single specimen done in the 
office once, rather than consecutive specimens. 
 
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 82270 have not been met. Therefore, we decided that the Plan 
does not have to pay for the services described by procedure code(s) 82270. 
 
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.