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Audit queue/ AUD-2026-04-0001/ CLM-0000021
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Post-pay review · Bayou Oncology Associates

Medicare Advantage Member MBR-30772614 DOS 19 Mar 2026 Paid 31 Mar 2026 · $8,069.76 Recovery window closes in 44 days
Eligibility: Active on the date of service Wellcare Medicare Advantage HMO · Louisiana Prior auth: Approved — claim exceeds what was authorised Drug and biologic
Review determination letter

As paid vs. as it should have been

Overpaid $1,344.96
LnCodeDescription PaidShould be VarianceResult
1 J9299 Injection, nivolumab, 1 mg
C34.90 · Malignant neoplasm of bronchus or lung, unspecified
 $8,069.76 $6,724.80 $1,344.96 Overpaid

Determination

3 of 3 layers

Separated so a provider can dispute the layer they disagree with, and so a reviewer can see which question was decided.

Coding defect Whether the code, level, units or sequencing follow the coding rule.
F-01
240 units billed against a 200 mg documented dose
The medication administration record for 19 March documents 200 mg administered. J9299 bills in 1 mg units, so 200 mg is 200 units. The 40 units above that are recoverable at the 2026 Q2 ASP rate of $33.624 per unit.
$1,344.96 Edit
Clinical-evidence defect Whether the record supports the condition or service that was coded.
PA
The authorization approves 200 mg per cycle
PA-2026-219044 approved nivolumab at 200 mg every two weeks. The claim bills 240 mg. Under CPP-085 v3.4 the excess above an authorization is reviewable even though the therapy itself was approved.
Supporting Edit
Payment consequence What it costs, and how the recoverable amount is computed.
AMT
$1,344.96 recoverable
Recover the 40 units billed above the documented and authorised dose
$1,344.96 Edit
Context, not part of the determination

These inform the reviewer. None of them is a reason the claim is wrong, and presenting them beside the defect is how an advisory becomes an allegation.

MUE
The unit edit passes this line — that is not the same as validating it
The MUE ceiling for J9299 in the practitioner setting is 480 units, so an automated unit edit lets 240 through without comment. CPP-061 v2.0 exists precisely because the ceiling is a maximum rather than an allowance.
Advisory

How it was coded

Up-coded
Billed J9299 × 240 units — 240 mg
Supported by the record J9299 × 200 units — 200 mg, per the medication administration record

Remedy: Recover the 40 units billed above the documented and authorised dose

Up-coding by unit count on a drug line. The drug, the diagnosis and the cycle are all right; the quantity is not. On a $33.62 billing unit a 40-unit overstatement is worth more than most coding errors in this batch put together.

Prior authorization

Approved — claim exceeds what was authorised
Authorization PA-2026-219044
Approved 2026-02-26
Valid 2026-03-01 → 2026-05-31
What was authorised Nivolumab 200 mg per cycle, every two weeks, six cycles
What was billed 240 units on 19 Mar 2026 — 240 mg, 40 mg above the authorised dose

The drug itself was authorised, so CPP-085 v3.4 bars a post-service medical-necessity review of the therapy. What is reviewable is the part of the claim that went beyond the authorization: units billed above those approved are recoverable under the same policy. The authorization and the infusion record agree with each other and disagree with the claim.

Policy applied

Knowledge Center

Resolved as at the date of service, 19 Mar 2026 — not as at today.

CPP-061 Physician-administered drugs — dose, units and wastage Decisive

Governs how billed units are reconciled against the dose recorded in the infusion record, and says in terms that passing the MUE is not validation

In force on 19 Mar 2026: v2.0 effective 2026-03-01
From CPP-061 v2.0, retrieved for this claim
p1 CPP-061_physician-administered-drugs_v2.0.md 0.233

CPP-061 — Physician-administered drugs: dose, units and wastage Version 2.0 · Effective 1 March 2026 · Supersedes v1.4 Owner: Pharmacy Payment Integrity Applies to: Medicare Advantage · Medicaid · Marketplace — all states External basis: CMS Part B ASP pricing file · Medically Unlikely Edits · JW / JZ modifier…

p1 CPP-061_physician-administered-drugs_v2.0.md 0.227

2. What changed in version 2.0 Version 1.4 accepted billed units at or below the published Medically Unlikely Edit ceiling for the code without any reconciliation to the administered dose. That is no longer sufficient. Three changes take effect on 1 March 2026: 1. Billed units must reconcile to the administered dose…

v2.0 had been in force for 18 days when this service happened. Before it, v1.4 applied — “Baseline drug-unit policy. Units at or below the MUE ceiling were accepted without reconciliation to the administered dose.”
CPP-080 Eligibility, enrolment and retroactive termination Supporting

Coverage on the date of service, and the re-verification at audit

In force on 19 Mar 2026: v6.1 effective 2026-01-01

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.

CPP-085 Prior authorization and post-service review Supporting

Makes units billed beyond those authorised reviewable and recoverable even where the therapy itself was approved

In force on 19 Mar 2026: v3.4 effective 2025-11-01

v3.4 was extracted from CPP-085_prior-authorization-post-service-review_v3.4.md. Passages are quoted only on the policy the finding rests on.

Source document

Open all four views
837P_20260322_476306.edi
Availity clearinghouse · EDI 837P · received 22 Mar 2026 11:31 · claim control CCN-0387126116
Claim form As received EDI Remittance

How this was decided

Open the full trace

Walked through Drug and biologic unit review v1.2, signed off 2026-02-20.

Procedure SOP-DRX-01 — Physician-administered drugs billed on the medical benefit
Nodes walked 13
Model calls 0 — every node that resolved did so on a rule, a lookup or arithmetic

Audit trail

Provider & member context
26 Feb 14:20 Prior authorization PA-2026-219044 approved, 200 mg per cycle Utilization management
31 Mar 09:40 Claim paid, $8,069.76 released to provider Payment cycle
02 Apr 18:02 Selected by drug and biologic spend criteria Autonomize
02 Apr 18:03 CPP-061 resolved to v2.0, the version in force on 19 Mar 2026 Autonomize
02 Apr 18:03 Finding drafted with 5 evidence items Autonomize
03 Apr 08:41 Assigned to D. Mercer, professional claims audit Routing