Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay an additional amount for the inpatient services billed as hc chg level IV 
surg pathology gross & microscopic exam, hc hemodialysis procedure w/phys/qhp evaluation and hc 
miscellaneous send out lab. We decided that the Plan does not have to pay an additional amount for the 
inpatient services billed as forceps endoscopic forcps radial jaw cold 1333-20 endoscopic, hc Cath 2 lumen 
Quinton, hc chg gluc bld gluc mntr dev cleared fda spec home use, hc chg glucose quantitative blood xcpt 
reagent strip, hc drape angiopack, hc drape brachial and hc pressurized/nonpressurized inhalation treatment.  
 
You asked the Plan to pay an additional amount for the inpatient services provided on May 6, 2018, through 
July 2, 2018. You say that you would like reconsideration based on the records submitted. The Plan says that 
the documentation submitted does not support the services billed. 
 
We decided that the Plan has to pay an additional amount for the inpatient services billed as hc chg level 
IV surg pathology gross & microscopic exam, hc hemodialysis procedure w/phys/qhp evaluation and hc 
miscellaneous send out lab.  
 
The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent 
efforts to gather and forward information to the IRE. 
 
We looked at your request, the file and Medicare rules. Based on this information we have determined that 
Medicare criteria for coverage of the inpatient services billed as hc chg level IV surg pathology gross & 
microscopic exam, hc hemodialysis procedure w/phys/qhp evaluation and hc miscellaneous send out lab have 
been met. Specifically, the Plan has not forwarded sufficient information to substantiate their denial. It is the 
burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay an additional 
amount for the inpatient services billed as hc chg level IV surg pathology gross & microscopic exam, hc 
hemodialysis procedure w/phys/qhp evaluation and hc miscellaneous send out lab.  
 
We also decided that the Plan does not have to pay an additional amount for the inpatient services billed 
as forceps endoscopic forcps radial jaw cold 1333-20 endoscopic, hc Cath 2 lumen Quinton, hc chg gluc 
bld gluc mntr dev cleared fda spec home use, hc chg glucose quantitative blood xcpt reagent strip, hc 
drape angiopack, hc drape brachial and hc pressurized/nonpressurized inhalation treatment. 
 
The Plan follows Medicare rules. Medicare rules 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. 
 
We looked at your request, the file and Medicare rules. Based on this information, we have determined that 
Medicare criteria for coverage of the inpatient services billed as forceps endoscopic*forcps radial jaw cold 
1333-20 endoscopic, hc Cath 2 lumen Quinton, hc chg gluc bld gluc mntr dev cleared fda spec home use, hc 
chg glucose quantitative blood xcpt reagent strip, hc drape angiopack, hc drape brachial and hc 
pressurized/nonpressurized inhalation treatment have not been met. Specifically, these items and services are 
considered inclusive to the room and board charge and are not separately payable. Therefore, we decided that 
the Plan does not have to pay an additional amount for the inpatient services billed as forceps endoscopic 
forcps radial jaw cold 1333-20 endoscopic, hc Cath 2 lumen Quinton, hc chg gluc bld gluc mntr dev cleared fda 
spec home use, hc chg glucose quantitative blood xcpt reagent strip, hc drape angiopack, hc drape brachial and 
hc pressurized/nonpressurized inhalation treatment. 
 
 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.