Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 
87641, 87500, 87651, 87471, 87493, 87529, 87563, 87653, and 87561 billed for July 6, 2023. 
 
You asked the Plan to pay for these services. You say that you dsiagree with the denial. The Plan denied your 
request. The Plan says the codes 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 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. The definition of code 87491 is infectious agent 
detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique. The definition of 
code 87563 is infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, 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 87653 is infectious agent detection 
by nucleic acid (DNA or RNA); Streptococcus, group B, 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 87641 is infectious agent detection by nucleic acid (DNA or 
RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique. The definition of code 87500 is 
infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species 
van A, van B), 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 definintion of code 87471 is 
infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, 
amplified probe technique. The definition of code 87493 is infectious agent detection by nucleic acid (DNA or 
RNA); Clostridium difficile, toxin gene(s), amplified probe technique. The definition of code 87529 is 
infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique. 
The definition of code 87563 is infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma 
genitalium, amplified probe technique. The definition of code 87653 is infectious agent detection by nucleic 
acid (DNA or RNA); Streptococcus, group B, amplified probe technique. The defintion of code 87561 is 
infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, amplified probe 
technique. 
 
We find that CPT codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, 87500, 87651, 87471, 87493, 
87529, 87563, 87653, and 87561 are not supported in the medical record. Specifically, the records show that 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 87481, 87491, 87563, 87640, 87653, 87798, 87641, 87500, 
87651, 87471, 87493, 87529, 87563, 87653, and 87561 billed for July 6, 2023.