Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87486, 87496, 87498, 87502, 87532, 87541, 
87581, 87640, 87651, 87798, and U0005 billed for January 10, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, 
87798, and U0005 are not supported. 
 
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 87486 is infectious agent detection by nucleic acid (DNA 
or RNA); Chlamydia pneumoniae, amplified probe technique. The definition of code 87496 is infectious agent 
detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique. The definition of code 
87498 is infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique, includes reverse transcription when performed. The definition of code 87502 is infectious agent detection by 
nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse 
transcription, when performed, and multiplex amplified probe technique, first 2 types or sub-types. The 
definition of code 87532 is infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, 
amplified probe technique. The definition of code 87541 is infectious agent detection by nucleic acid (DNA or 
RNA); Legionella pneumophila, amplified probe technique. The definition of code 87581 is infectious agent 
detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, amplified probe technique. The definition 
of code 87640 is infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified 
probe technique. The definition of code 87651 is infectious agent detection by nucleic acid (DNA or RNA); 
Streptococcus, group A, amplified probe technique. The definition of code 87798 is infectious agent detection 
by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism. The 
definition of code U0005 is infectious agent detection by nucleic acid (dna or rna); severe acute respiratory 
syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, cdc or non-
cdc, making use of high throughput technologies, completed within 2 calendar days from date of specimen 
collection (list separately in addition to either hcpcs code u0003 or u0004) as described by cms-2020-01-r2. 
 
We find that CPT codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, 87798, and U0005 
are not supported in the medical record. Specifically, a panel was performed and there is a more appropriate 
single code for the services. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, 87798, and U0005 billed for January 10, 
2023.