As paid vs. as it should have been
| Ln | Code | Description | Paid | Should be | Variance | Result |
|---|---|---|---|---|---|---|
| 1 | 72148 |
MRI, lumbar spine, without contrast material
M54.50 · Low back pain, unspecified
|
$254.18 | $0.00 | $254.18 | Not covered |
Determination
No coding defect. The code, the units and the sequencing are what the claim should carry; the disagreement is not about coding.
How it was coded
Remedy: None — the code, the unit count and the site of service are what the record supports
Reviewed for level, unit count, modifier and site. Nothing is wrong with how this study was coded. The disagreement is about whether the study should have been performed at all, which is a clinical question, not a coding one.
Prior authorization
This is why the finding is reachable. Under CPP-085 v3.4 an approved authorization bars post-service medical-necessity review of the authorised service; with no authorization on file that bar does not apply, and the criterion in CPP-070 is reviewable after payment. Had the provider obtained one, this review would have been limited to coding and pricing — both of which are correct.
Policy applied
Knowledge CenterThe repeat-imaging criterion that this study fails, in the version in force on the date of service
No source document for v1.3 is in the index, so this policy can be cited here but not quoted. Upload it.
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.
Why a post-service medical-necessity review is open here — there is no authorization on file to close it
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.