Top denial reasons for codes L1900-L1990, L2000, L2005, L2010-L2136, L4350-L4387, L4396-L4397, L4631

1. The code on the claim is not correct for the item billed.
2. The documentation does not contain a valid standard written order (SWO).
3. No medical record documentation was received.
4. The medical records do not confirm that the coverage criteria have been met for an orthotic used during ambulation.
5. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
6. The standard written order (SWO) is missing a description of the item.
7. The medical records do not confirm that the coverage criteria have been met for an orthotic not used during ambulation.
8. The treating practitioner's order, supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity.

Top denial reasons for codes E0163 & E0165:

1. The medical record documentation does not support that one of the 3 criteria have been met for a commode.
2. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
3. The standard written order (SWO) is missing a description of the item.
4. No medical record documentation was received.
5. The supplier indicates the item was billed in error.
6. The documentation does not contain a valid standard written order (SWO).

Top denial reasons for codes A7027-A7034, A7044, E0601:

1. The standard written order (SWO) is missing a description of the item.
2. Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary.
3. Documentation does not include a valid in-person evaluation that meets all LCD requirements.
4. The documentation was not timely (within the preceding 12 months) to support continued need by the beneficiary.
5. Documentation does not include a valid sleep study that meets all LCD requirements.
6. The documentation does not contain a valid standard written order (SWO).
7. The claim is billed for greater quantity than the order indicates.
8. The medical record documentation does not contain a clinical evaluation by the treating practitioner prior to the sleep test.
9. There is no documentation to support the provider of the CPAP device conducted education on the proper use and care of the device.
10. The documentation submitted is incomplete.

Top denial reasons for codes: B43034 & B4035:

1. The feeding supply kit does not correspond with the method of enteral nutrition administration.
2. The medical record documentation does not establish that the beneficiary's condition is permanent.
3. The documentation does not contain a valid standard written order (SWO).
4. The standard written order (SWO) is missing a description of the item.
5. Payment for supplies or items billed in excess of the quantity considered to be reasonable and necessary is being denied.
6. No medical record documentation was received.
7. The medical record documentation does not provide justification for the use of a pump.
8. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
9. Medical record documentation indicated that the enteral nutrition was being administered orally.
10. The medical record documentation does not specify why a standard formula cannot be used to meet the beneficiary's metabolic needs.

Top denial reason codes: E2103, A4239, A4253:

1. No medical record documentation was received.
2. Medical Records and/or beneficiary testing logs do not meet the LCD requirements for billing over-utilization amounts.
3. The medical record documentation does not support the beneficiary had an in-person or Medicare-approved telehealth visit with their treating practitioner to assess adherence to their continuous glucose monitor (CGM) regimen and diabetes treatment plan every 6 months following the initial prescription of the CGM.
4. Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary.
5. The documentation does not contain a valid standard written order (SWO).
6. Quantity of supplies ordered is above normal allowable amounts and no medical records were sent in to address the need for over-utilization. Medical records and a test log or narrative by the practitioner are required to support the requirements in the ‘high utilization' section of the LCD.
7. Claim history shows that the supplier has already been paid for all or a portion of the medically necessary supplies for this time span. Therefore, the excess units are being denied.
8. Payment for this item is included in the allowance for another item provided at the same time.
9. The medical record documentation does not support the beneficiary has diabetes.
10. The medical record documentation does not support the beneficiary had an in-person or Medicare-approved telehealth visit with their treating practitioner to evaluate their diabetes control and determined that criteria are met within 6 months prior to ordering the continuous glucose monitor (CGM).

Top reasons denial for codes E0260, E0261, E0303

1. Medical records do not support that the beneficiary requires frequent changes in body position and/or has an immediate need for a change in body position.
2. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
3. The standard written order (SWO) is missing a description of the item.
4. The supplier indicates the item were billed in error.
5. The treating practitioner's order, supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity.
6. The standard written order (SWO) was missing the date of the order and the start date of the order (if different from the order date).

Top denial reasons for codes J7503, J7507, J7518, J7520, J7527

1. The documentation submitted is incomplete.
2. The claim is billed for greater quantity than the order indicates.
3. The quantity of drugs dispensed is limited to a 1-month supply. Quantities of drugs dispensed in excess of a 1-month supply will be denied as not medically necessary.
4. Documentation does not include information that supports that the beneficiary had a Medicare approved transplant per LCD/Policy Article requirements.
5. The documentation does not contain a valid standard written order (SWO).

Top denial reasons for codes L1832, L1843, L1844, L1845, L1851, L1852, L2397:

1. The file does not include medical records that support an examination of knee instability and an objective description of joint laxity (i.e., joint testing, anterior draw, posterior draw, valgus/varus test) from the treating practitioner.
2. No medical record documentation was received.
3. The medical record documentation does not support the beneficiary has had a recent injury or a surgical procedure on the knee.
4. The documentation does not contain a valid standard written order (SWO).
5. The medical record does not contain one of the diagnoses required by the LCD.
6. The documentation submitted is incomplete.
7. The claim was submitted with an incorrect modifier.

Top denial reasons for codes K0001-K0004:

1. The medical records do not document that the beneficiary either has sufficient upper extremity function and other physical and mental capabilities needed to, in the home during a typical day, safely self-propel the manual wheelchair that is provided or has a caregiver who is available, willing, and able to provide assistance with the wheelchair.
2. Neither the medical records nor supplier documentation included a home assessment.
3. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
4. The standard written order (SWO) is missing a description of the item.
5. The medical record documentation does not indicate the beneficiary's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.
6. The supply or accessory is denied as the base equipment is denied.
7. The medical record documentation does not support that use of a manual wheelchair will significantly improve the beneficiary's ability to participate in mobility related activities of daily living and the beneficiary will be using it on a regular basis in the home.
8. Medical records do not support that the beneficiary requires a lower seat height (17" to 18") because of short stature or to enable the beneficiary to place his/her feet on the ground for propulsion.
9. The documentation does not contain a valid standard written order (SWO).
10. The records do not document that the beneficiary's condition requires a K0003 due to the inability to self-propel a standard wheelchair in the home and that the beneficiary can and does self-propel a lightweight wheelchair.

Top denial reasons for codes J7605, J7606, J7613, J7620, J7626:

1. No medical record documentation was received.
2. The number of units listed on the claim is above the LCD policy allowance.
3. The medical record documentation does not support the beneficiary has obstructive pulmonary disease.

Top denial reasons for codes E0424, E0439, E1390, E1391:

1. The medical record documentation does not support any of the Group I criteria.
2. The medical record documentation does not support the treating practitioner has evaluated the results of a qualifying blood gas study performed.
3. The documentation does not contain a valid standard written Order (SWO).
4. The standard written order (SWO) is missing a description of the item.
5. The medical record documentation does not contain a blood gas study performed at rest or during exercise to support a portable oxygen system.
6. The medical record documentation does not include a blood gas study.
7. The medical record documentation does not support the blood gas study was obtained within 2 days prior to discharge from an inpatient hospital stay.
8. The medical record documentation does not support that the qualifying blood gas study was performed at the time of need.
9. The supplier indicates the items were billed in error.
10. No medical record documentation was received.

Top denial reasons for codes L0450-L0651:

1. Medical records do not support one of the four criteria for a spinal orthosis.
2. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
3. No medical record documentation was received.
4. The code on the claim is not correct for the item billed.
5. The documentation does not contain a valid written order prior to delivery (WOPD).
6. The documentation does not include a valid face-to-face encounter.
7. The documentation submitted indicates the item was returned by the beneficiary.
8. The documentation does not contain a valid standard written order (SWO).
9. The documentation submitted is incomplete.
10. The treating practitioner's order, supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity.

Top denial reasons for codes A6010, A6021, A6196-A6199, A6203, A6209-A6212, A6231-A6233, A6234-A6241, A6242-A6248, A6251-A6256:

1. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
2. The size of the wound in the medical records does not support the code being billed.
3. Frequency of use or frequency of change is not supported by the medical records.
4. Medical records do not support that the surgical dressings are required for either the treatment of a wound caused by, or treated by, a surgical procedure; or when required after debridement of a wound.
5. The monthly evaluation of the wound by the healthcare professional did not include the type of each wound, its location, its size and depth, the amount of drainage and any other relevant information.
6. The medical records do not establish that the dressing is being used as a primary or secondary dressing or for some non-covered use (Example: wound cleansing).
7. The standard written order (SWO) is missing a description of the item.
8. Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary.
9. The medical records do not show that the foam dressing is being used on a full thickness wound with moderate to heavy exudate (Stage III or Stage IV ulcer).
10. This item or service is denied non-covered.

Top denial reasons for codes A5500, A5512, A5513:

1. Medical record documentation does not include a clinical foot evaluation either conducted by the certifying physician or approved, initialed and dated by the certifying physician. Therefore, there is no verification that the beneficiary had one of the 6 conditions the LCD specifies must be present for coverage.
2. Medical records do not include a certifying physician clinical evaluation which discusses the management of the beneficiary's systemic diabetes condition within 6 months prior to shoe delivery.
3. The file does not include medical records from the certifying physician.
4. The Statement of Certifying Physician is dated prior to a documented visit with the certifying physician.
5. Documentation did not include an in-person supplier visit at the time of delivery that assessed the fit of the shoes and inserts with the patient wearing them.
6. Documentation did not include an in-person evaluation of the patient's feet conducted by the supplier prior to selection of the specific items.
7. The in-person evaluation of the patient's feet is missing a description of the abnormalities the shoes/inserts/modifications will need to accommodate.
8. The examination documenting the medical management of the patient's diabetes may only be performed by a doctor of osteopathy (D.O.), medical doctor (M.D.), or nurse practitioner (NP) or physician assistant (PA) practicing "incident to" the supervising physician's authority. NP or PA notes pertaining to the provision of the therapeutic shoes and inserts must be reviewed and verified by the supervising physician.
9. Documentation did not include a Statement of Certifying Physician.
10. The Statement of Certifying Physician was signed more than 3 months prior to delivery of the shoes/inserts.

Top denial reasons for codes A4316, A4351, A4352, A4353, A4355:

1. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
2. The medical records from the treating practitioner do not document an impairment of urination.
3. No medical record documentation was received.
4. The submitted medical records do not document the medical necessity for a coude (curved) tip catheter. (Example: An inability to catheterize with a straight tip catheter)
5. The claim is billed for greater quantity than the order indicates.
6. The standard written order (SWO) contains a treating practitioner's signature which does not comply with the Centers for Medicare & Medicaid Services signature requirements.
7. The documentation does not contain a valid standard written order (SWO).
8. Multiple suppliers are billing for overlapping dates of service and payment has already been made for all or a portion of the medically necessary supplies for this time span.
9. Claim history shows that the supplier has already been paid for all or a portion of the medically necessary supplies for this time span. Therefore, the excess units are being denied.
10. Sterile lubricant is not separately payable when the supplier bills for code A4353. Payment for the lubricant is included in the fee schedule for the kit.