Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for codes 87530, 87563, 87652, 87482 and 87552. We decided that the 
Plan does not have to pay for codes 87500, 87640, 87641, 87653, 87798, 87799 and 87498.  
 
You asked the Plan to pay for laboratory services provided on December 14, 2022, billed with codes 87500, 
87640, 87641, 87653, 87798, 87799, 87498, 87530, 87563, 87652, 87482 and 87552. You say that you have 
billed the services at issue correctly. The Plan says that rules for payment have not been met. 
 
We decided that the Plan has to pay for codes 87530, 87563, 87652, 87482 and 87552.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that codes 87530, 87563, 87652, 87482 and 87552 are supported in the 
provided medical records. Therefore, we decided that the Plan has to pay for codes 87530, 87563, 87652, 
87482 and 87552.  
 
We also decided that the Plan does not have to pay for codes 87500, 87640, 87641, 87653 and 87798. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that the panel denoted by codes 87500, 
87640, 87641, 87653 and 87798 used the nucleic acid probe technique. There is no evidence that multiple 
procedures, multiple methodologies, or multiple kits were used in this case. As such, a single code with one 
unit of service should be used. Based on this information, we decided that Medicare rules for coverage of the 
testing panel have not been met. Therefore, we decided that the Plan does not have to pay for codes 87500, 
87640, 87641, 87653 and 87798. 
 
We also decided that the Plan does not have to pay for codes 87799 and 87498. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of codes 87799 and 87498 have been met. 
Specifically, there is insufficient information in the provided medical records that the services denoted by 
codes 87799 and 87498 were rendered on the date of service at issue. Therefore, we decided that the Plan does 
not have to pay for codes 87799 and 87498. 
 
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.