Diagnosis: Rash over body
Treatment: Current Procedural Terminology (CPT) code 87633 - CS infectious agent detection by nucleic acid (DNA or RNA); respiratory virus, includes multiplex reverse transcription when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets with diagnosis code Z20.822
The insurer denied coverage for Current Procedural Terminology (CPT) code 87633 - CS infectious agent detection by nucleic acid (DNA or RNA); respiratory virus, includes multiplex reverse transcription when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets with diagnosis code Z20.822
The denial is overturned

This patient is a child who presented for evaluation of a rash on the legs, trunk, and back, after recently having finished a course of penicillin for a strep infection. When presented with a child with a rash that is not immediately pathognomonic for an infection (e.g. varicella, measles, Coxsackie), it is clinically imperative to distinguish an allergic reaction from an infection. In the case of this child, this was particularly important because of the recent streptococcal infection that was treated with a penicillin, and therefore it was important to decide if this rash had an alternative explanation so that the child could be appropriately labeled as possibly allergic to the antibiotic or not. Moreover, an infectious illness could progress from rash to other symptoms and may need further medical attention in the next few days.

The insurer has not provided any evidence for the statement "not enough proof that testing of genetic material for greater than five respiratory infectious pathogens improve clinical outcomes." The insurer needs to cite published literature for evidence. Identifying a virus or other pathogen by nucleic acid amplification provides invaluable clinical benefit. This aids in antimicrobial stewardship, as well as allows assignment of an etiology to the illness. One specific example of an infectious cause for a generalized diffuse papular urticarial rash that is identifiable by an Respiratory Virus Panel (RVP) is Mycoplasma. Moreover, he needed to be tested for COVID (Corona Virus) as he was exposed 5 days earlier, and it is effective and medically indicated to test for other viruses at the same time.

The health plan did not act reasonably, with sound medical judgment and/or in the best interest of the patient.

The insurer's denial of coverage for the current procedural terminology (CPT) code 87633 - CS infectious agent detection by nucleic acid (DNA or RNA); respiratory virus, includes multiplex reverse transcription when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets with diagnosis code Z20.822 is overturned.

Medical necessity is substantiated.