Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 87651, 87491, 87591, 
87481, 87563, 87591, 87563, 87529, and 81003. We decided that the Plan does not have to pay for the services 
described by procedure code(s) 87798, 87640, 87653, and 87661.  
 
You asked the Plan to pay for procedure codes 87651, 87491, 87591, 87481, 87563, 87591, 87563, 87529, 
81003, 87798, 87640, 87653, and 87661 provided on April 17, 2023. You say that you would like the Plan to 
reconsider their denial of payment. The Plan says that the services are not covered as billed. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 87651, 87491, 87591, 
87481, 87563, 87591, 87563, 87529, and 81003.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 87651, 87491, 87591, 87481, 
87563, 87591, 87563, 87529, and 81003.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
87798, 87640, 87653, and 87661. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units. 
 
In this case, the MUE for CPT code 87798 is 13. The MAI value for this code is 3. You billed 26 units of this 
code, exceeding the MUE. The MUE for CPT codes 87640, 87653, and 87661 is 1. The MAI value for these 
codes is 3. You billed 2 units each of these codes, exceeding the MUE. You did not provide all the required evidence showing that the excess units were actually provided, were correctly coded, and were medically 
necessary. Based on this information, we decided that Medicare rules for coverage of the services described by 
procedure code(s) 87798, 87640, 87653, and 87661 have not been met. Therefore, we decided that the Plan 
does not have to pay for the services described by procedure code(s) 87798, 87640, 87653, and 87661. 
 
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.