As paid vs. as it should have been
| Ln | Code | Description | Paid | Should be | Variance | Result |
|---|---|---|---|---|---|---|
| 1 | 29881 |
Arthroscopy, knee, surgical, with meniscectomy
M23.221 · Derangement of posterior horn of medial meniscus due to old tear, right knee
|
$512.88 | $512.88 | — | Correct |
Determination
Reviewed with no variance. Every line was paid at the allowable on file.
How it was coded
Remedy: None — the claim was billed and priced as the record supports
Reviewed for level, severity and unit count. Nothing billed above what the record carries.
Prior authorization
The authorization lapsed three days before the service. Under CPP-085 v3.4 the service is reviewable, but this is an authorization gap rather than a coding or pricing variance — it is referred to utilization management, not recovered here.
Policy applied
Knowledge CenterWhether the authorization on file covers the service billed
3. Criteria 3.1 An authorization on file A service with an approved authorization on file, performed within the authorised date range and at the authorised site, is not denied post-service for medical necessity. A reviewer who believes the authorization was granted in error refers the matter to utilization management…
4. Variations by state and line of business 4.1 Texas — gold-carding Texas House Bill 3459 exempts a provider whose prior-authorization requests for a given service were approved at or above the statutory rate in the preceding evaluation period from having to obtain authorization for that service. An exempt provider…
Coverage on the date of service
v6.1 was extracted from CPP-080_eligibility-enrolment-retroactive-termination_v6.1.md. Passages are quoted only on the policy the finding rests on.