Appeal type: Lab
Decision: Partially Favorable

 
You asked the Plan to pay for laboratory testing provided on July 5, 2023. You say that you are appealing with 
supporting records. The Plan says that these codes are not supported. 
 
We decided that the Plan has to pay for 83630, 87177, 87209, 87324.  
 
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 83630 is lactoferrin, fecal; qualitative. The CPT Code Manual definition of code 87177 is ova and 
parasites, direct smears, concentration and identification. The CPT Code Manual definition of code 87209 is 
smear, primary source with interpretation; complex special stain (e.g., trichrome, iron hemotoxylin) for ova and 
parasites. The CPT Code Manual definition of code 87324 is infectious agent antigen detection by 
immunoassay technique (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], 
fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; 
Clostridium difficile toxin(s) 
 
We asked our coding reviewer 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 item/service at issue. Our reviewer says 
that these codes meet criteria for payment. Our reviewer found the records contains evidence that these tests 
were ordered and performed.  
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for 83630, 87177, 87209, 87324.  
 
We also decided that the Plan does not have to pay for 83520. 
 
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 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, 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 83520. Our reviewer says that this code is not supported for 
payment. Our reviewer found the record does not specify what immunoassay was tested and reported with this 
code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 83520 have not been met. Therefore, we decided that the Plan does not 
have to pay for 83520. 
 
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.