As paid vs. as it should have been
| Ln | Code | Description | Paid | Should be | Variance | Result |
|---|---|---|---|---|---|---|
| 1 | J9355 |
Injection, trastuzumab, excludes biosimilar, 10 mg
C50.911 · Malignant neoplasm of right female breast, unspecified site
|
$3,083.85 | $3,083.85 | — | 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
420 mg divided by the code's 10 mg billing unit is 42 units. The claim, the record and the authorization all say the same number — under CPP-061 v1.4, the version in force when the drug was given. v2.0 arrived five days later.
Prior authorization
The same provider, the same benefit and the same policy as CLM-0000021, and here the units reconcile. This is what the drug-spend criterion is measured against: without the claims it clears, the ones it catches prove nothing.
Policy applied
Knowledge CenterGoverns how billed units are reconciled against the documented dose. Resolves to v1.4 here, not the v2.0 an auditor would find today
code and setting are payable as submitted. No further reconciliation against the clinical record is required for a claim within the ceiling. 2.2 Units above the ceiling Units above the Medically Unlikely Edit ceiling are reviewed against the clinical record. The reviewer requests the medication administration record…
2.3 Unit calculation Where reconciliation is required, billed units equal the administered dose divided by the billing unit published in the HCPCS long descriptor, rounded to whole units. 2.4 Wastage Drug discarded from a single-dose vial is payable where the discarded amount is recorded in the clinical record…
Coverage on the date of service, and the re-verification at audit
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.
The authorization on file, and what it closes off from post-service review
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.