Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the Surgical Cellulose 4in x 8in. We decided that the Plan does not 
have to pay for Anchor Polysorb No2 TI-Cron, 3mm Anchor Tissue Polysorb No2, Cath PowerPicc 5FR 
2Lum, Chlorhexidine Gluc 0.12% 118ml, Clinic Shoulder Immob XL, Clip Ligation Medium Horizon, Clip 
Ligation Small Hemoclip, Device Cor-knot 14cm w/Fasten, Drain Round 24FR, Eucalyptus/Menthol Lozenge, 
Insert PICC w/ Port 5+ Bedside, Introducer Glidesheath Kit, Oxygen Daily, POC Glucose by Monitor Device, 
Spec Coll Venous Venipuncture, Multiple types of sutures, Transfusion Blood/Products, and Mupirocin 2% 
22Gm Oint.  
 
You asked the Plan to pay for Anchor Polysorb No2 TI-Cron, 3mm Anchor Tissue Polysorb No2, Cath 
PowerPicc 5FR 2Lum, Chlorhexidine Gluc 0.12% 118ml, Clinic Shoulder Immob XL, Clip Ligation Medium 
Horizon, Clip Ligation Small Hemoclip, Device Cor-knot 14cm w/Fasten, Drain Round 24FR, 
Eucalyptus/Menthol Lozenge, Insert PICC w/ Port 5+ Bedside, Introducer Glidesheath Kit, Oxygen Daily, 
POC Glucose by Monitor Device, Spec Coll Venous Venipuncture, Multiple types of sutures, Transfusion 
Blood/Products, Mupirocin 2% 22Gm Oint and Surgical Cellulose 4in x 8in billed on the inpatient claim for 
services rendered on May 24, 2021, through July 19, 2021. You say that you would like reconsideration based 
on the records submitted. The Plan says that the items at issue are considered routine items and services or not 
supported by the record. 
 
We decided that the Plan has to pay for the Surgical Cellulose 4in x 8in.  
 
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 looked at your request, the file and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of Surgical Cellulose 4in x 8in have been met. Specifically, the documentation submitted 
does not support that Surgical Cellulose 4in x 8in was billed twice. Therefore, we decided that the Plan has to 
pay for the Surgical Cellulose 4in x 8in.  
 
We also decided that the Plan does not have to pay for Anchor Polysorb No2 TI-Cron, 3mm Anchor 
Tissue Polysorb No2, Cath PowerPicc 5FR 2Lum, Chlorhexidine Gluc 0.12% 118ml, Clinic Shoulder 
Immob XL, Clip Ligation Medium Horizon, Clip Ligation Small Hemoclip, Device Cor-knot 14cm 
w/Fasten, Drain Round 24FR, Eucalyptus/Menthol Lozenge, Insert PICC w/ Port 5+ Bedside, Introducer 
Glidesheath Kit, Oxygen Daily, POC Glucose by Monitor Device, Spec Coll Venous Venipuncture, 
Multiple types of sutures, Transfusion Blood/Products, and Mupirocin 2% 22Gm Oint. 
 
The Plan follows Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, 
must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the 
amount of payment. 
 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 pay for Mupirocin 2% 22Gm Oint. Our reviewer 
says that the documentation supports that only one unit of Mupirocin 2% 22Gm Oint was provided.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Mupirocin 2% 22Gm Oint have not been met. 
 
Medicare rules also say that inpatient routine services in a hospital or skilled nursing facility generally are those 
services included in by the provider in a daily service charge--sometimes referred to as the "room and board" 
charge. 
 
We looked at your request, the file and Medicare rules. Based on this information we have determined that the 
Anchor Polysorb No2 TI-Cron, 3mm Anchor Tissue Polysorb No2, Cath PowerPicc 5FR 2Lum, Chlorhexidine 
Gluc 0.12% 118ml, Clinic Shoulder Immob XL, Clip Ligation Medium Horizon, Clip Ligation Small 
Hemoclip, Device Cor-knot 14cm w/Fasten, Drain Round 24FR, Eucalyptus/Menthol Lozenge, Insert PICC w/ 
Port 5+ Bedside, Introducer Glidesheath Kit, Oxygen Daily, POC Glucose by Monitor Device, Spec Coll 
Venous Venipuncture, Multiple types of sutures and Transfusion Blood/Products are considered routine items 
and services. 
 
Therefore, we decided that the Plan does not have to pay for Anchor Polysorb No2 TI-Cron, 3mm Anchor 
Tissue Polysorb No2, Cath PowerPicc 5FR 2Lum, Chlorhexidine Gluc 0.12% 118ml, Clinic Shoulder Immob 
XL, Clip Ligation Medium Horizon, Clip Ligation Small Hemoclip, Device Cor-knot 14cm w/Fasten, Drain 
Round 24FR, Eucalyptus/Menthol Lozenge, Insert PICC w/ Port 5+ Bedside, Introducer Glidesheath Kit, 
Oxygen Daily, POC Glucose by Monitor Device, Spec Coll Venous Venipuncture, Multiple types of sutures, 
Transfusion Blood/Products, and Mupirocin 2% 22Gm Oint. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.