CPT 86695: Federal IDR outcomes
Analysis for antibody to Herpes simplex virus, type 1
In 2025 Q1–Q4, the provider or facility offer prevailed in 82.8% of 93 determined Federal IDR dispute line items for CPT 86695. The median prevailing offer was 4.44x the QPA (25th–75th percentile 3.14x–6.54x; n = 60). The median time to a decision was 28 business days (n = 93).
Determined line items
93
2025 Q1–Q4 · 0 split decisions excluded
Provider win rate
82.8%
n = 93 · 2025 Q1–Q4
Median payment vs QPA
4.44x
middle half 3.14x–6.54x · n = 60 · 2025 Q1–Q4
Median days to decision
28
business days, from dispute initiation · n = 93 · 2025 Q1–Q4
Dollar amounts
Fewer than 30 line items with dollar amounts in 2025 Q1–Q4; not shown.
Dollar amounts by period
| Period | Line items with $ | Total awarded | Total QPA | Above QPA | Median award | Median QPA | Award ×QPA ($-weighted) |
|---|---|---|---|---|---|---|---|
| 2025 Q1–Q4 | Fewer than 30 line items with dollar amounts; not shown. | ||||||
| 2024 Q3–Q4 | Fewer than 30 line items with dollar amounts; not shown. | ||||||
| 2024 Q3–2025 Q4 | Fewer than 30 line items with dollar amounts; not shown. | ||||||
| 2023 Q1–2024 Q2 | Not available (see methodology). | ||||||
From the CMS QPA and Offers file (see above). Award ×QPA here is total awarded ÷ total QPA, so large claims weigh more than in the per-line median ratio.
By period
| Period | Line items | Win % | Median ×QPA | 25th–75th | Ratio n | Median days |
|---|---|---|---|---|---|---|
| 2025 Q1–Q4 | 93 | 82.8% | 4.44x | 3.14x–6.54x | 60 | 28 |
| 2024 Q1–Q4 | Fewer than 30 determined line items; not shown. | |||||
| 2023 Q1–Q4 | Fewer than 30 determined line items; not shown. | |||||
| 2023 Q1–2025 Q4 | 108 | 83.3% | 4.57x | 3.21x–6.85x | 66 | not pooled |
Line items = determined dispute line items (n). Win rate excludes split decisions and includes default decisions. Ratio n = line items reporting a payment-to-QPA ratio. Days are business days as reported by CMS (2023–2024: from IDR entity assignment; 2025: from initiation) and are never pooled.
By state
| State (place of service) | Line items | Win % | Median ×QPA | Ratio n | Median days |
|---|---|---|---|---|---|
| Texas | 69 | 78.3% | 4.65x | 44 | 28 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
By specialty
| Specialty group | Line items | Win % | Median ×QPA | Ratio n | Median days |
|---|---|---|---|---|---|
| Emergency medicine and emergency departments | 69 | 82.6% | 4.42x | 55 | 30 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Section: Pathology and laboratory (80047–89398)
FAQ
What is the Federal IDR provider win rate for CPT 86695?
In 2025 Q1–Q4, the provider or facility offer was selected in 82.8% of 93 determined dispute line items for CPT 86695. Split decisions are excluded from the denominator and default decisions are included. Withdrawn, settled and ineligible disputes are not in the CMS data.
How do Federal IDR payments compare with the QPA for CPT 86695?
In 2025 Q1–Q4, the median prevailing offer was 4.44x the qualifying payment amount (QPA), with a 25th to 75th percentile range of 3.14x to 6.54x (n = 60 line items). This uses the CMS field Prevailing Party Offer as % of QPA, where 1.00x equals the QPA.
How long do Federal IDR decisions take for CPT 86695?
In 2025 Q1–Q4, the median was 28 business days (n = 93 line items), using the CMS field Length of Time to Make Determination (from dispute initiation).