Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services denied with code K. We decided that the Plan does not 
have to pay for the services denied with code G.  
 
You asked the Plan to pay for inpatient hospital services rendered from February 23, 2022, to April 28, 2022 
and denied with denial codes G and K. You say that this should be paid for. The Plan says that several items 
and services initially denied due to not having an itemized bill have now been identified as routine items and 
services. 
 
We decided that the Plan has to pay for the services denied with code K.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 for the services that were denied as duplicate with 
denial code K. The total claim charges for these services is $3,894.00. Our reviewer says that after a careful 
review of the denied charges, there is no evidence of any charges denied for duplicate. The charges are unable 
to be reviewed. The itemized bill does not have any lines that were denied for this reason.  
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
the services denied with code K.  
 
We also decided that the Plan does not have to pay for the services denied with code G. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 for the services denied with denial code G. The total 
claim charges for this denial reason were $228,772.88. Our reviewer says that the provider reported several 
different charges, which denied correctly, as these charges would be considered "routine." Non-
Reimbursable/Unbundled Charges means billed charges for hospital services, supplies, equipment and/or items 
for which the plan will not reimburse Institution based on the plans determination that such charges constitute 
unbundled, fragmented or otherwise duplicative charges which should reasonably be included in another 
charge which the institution has billed to the plan for the same patient on the same day. 
 
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 services denied with code G have not been met. Therefore, we decided that 
the Plan does not have to pay for the services denied with code G. 
 
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.