Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to apply additional reimbursement for hospital services provided on
June 2, 2020, through June 10, 2020.

You asked the Plan to apply additional reimbursement for the hospital services. You say that you would like
reconsideration for additional reimbursement. The Plan denied your request. The Plan says the documentation
does not substantiate whether the remaining adjustments are payable as billed.

The Plan follows Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for
any item or service, the information submitted by the supplier or provider must corroborate the documentation
in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to apply additional reimbursement for the hospital
services.

Our reviewer says that the submitted documentation does not substantiate whether the remaining adjustments are payable as billed. Since no additional clarifying information was received to address each specific line item adjustment, the rationale regarding the line item adjustments that was presented in the 1st Level response remains unchanged. The documentation does not support that the provider incurred incremental costs for providing services and supplies that appear to be integral to the underlying room and/or procedure charges Our physician reviewer found the following: 

Regarding the HC CLAMP ISOLATOR; there is no documentation showing how these supplies are outside of the standard of care. 

Regarding HC ART CATH SAMPLING/MONITORNG; HC MDI/OPP DEMO/EVAL; these items are components of the underling room or procedure charges. It is not appropriate to bill these services separately. 

Regarding HCVENIPUNCTURE; this service is an essential part of performing the test. The reimbursement is included in the lab test procedure code. It is not appropriate to bill this separately. 

Regarding HC GLUCOSE POC; the documentation does not show why these charges were separately billed or how incremental costs were incurred. 

Regarding HC CALCIUM IONIZED; HC HEMATOCRIT; HC LACWB LACTATE; HC MAGNESIUM SERUM/PL; HC POTASSIUM; these charges were obtained from the same underlying sample and analysis as a separately reimbursed lab test charge. The documents do not show that the provider incurred additional cost to obtain these results. 

Regarding HC CARBON DIOXIDE EXP GAS DETER INFRARED ANALYZER; this is an integral component of separately reimbursed respiratory therapy. There is no documentation for separate billing for this. 

Regarding D5W SOLP 250 ML BAG; NS (PF) 0.9% SOLN 10 ML VIAL; NS 0.9 % SOLP; NS 0.9 % SOLP 100 ML BAG; NS 0.9 % SOLP 50 ML FLEX CONT; the documentation does not show why these items are not considered components of the underlying room and board, medication, treatments or therapies. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met. Therefore, we decided that the Plan does not have to apply additional reimbursement for hospital services provided on June 2, 2020, through June 10, 2020.