Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code U0003. We decided that the Plan does not have to pay 
for procedure codes U0005, 87486, 87498, 87502, 87581, 87633, 87634, 87640, 87651, and 87798.  
 
You asked the Plan to pay for the lab testing billed for date of service April 21, 2023. You say that the 
physician determined the test was medically necessary. The Plan says that one code must be submitted for the 
panel. 
 
We decided that the Plan has to pay for procedure code U0003.  
 
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 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. 
 
We find that CPT code U0003 supported in the medical record. The lab results show that Covid-19 testing was 
provided separate from the panel test. Based on this information, we decided that Medicare rules for coverage 
of have been met. Therefore, we decided that the Plan has to pay for procedure code U0003 billed for date of 
service April 21, 2023.  
 
We also decided that the Plan does not have to pay for procedure codes U0005, 87486, 87498, 87502, 
87581, 87633, 87634, 87640, 87651, and 87798. 
 
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 
code. 
 
The file shows that a respiratory panel test 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.  
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 looked at the file and the rules. We find that code U0005 is not supported. The lab results do not show that 
Covid-19 testing, billed with code U0003, was completed within 2 calendar days from the date of collection. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes U0005, 87486, 87498, 87502, 87581, 87633, 
87634, 87640, 87651, and 87798 billed for date of service April 21, 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.