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

1. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met.
2. The documentation does not contain a valid Standard Written Order (SWO).
3. The medical records do not confirm that the coverage criteria have been met for an orthotic used during ambulation.
4. The code on the claim is not correct for the item billed.
5. The medical records do not confirm that the coverage criteria have been met for an orthotic not used during ambulation.
6. No medical record documentation was received.
7. Documentation provided in the supplier’s records and the treating practitioner’s medical record do not support the medical necessity of a custom fabricated orthosis rather than a prefabricated orthosis.
8. The claim was submitted with an incorrect modifier.
9. The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident.
10. The supplier indicates the item(s) were billed in error.

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

1. The standard written order (SWO) is missing a description of the item.
2. The documentation was not timely (within the preceding 12 months) to support continued need by the beneficiary.
3. Documentation does not include a valid in-person evaluation that meets all LCD requirements.
4. Documentation does not include a valid sleep study that meets all LCD requirements.
5. The claim is billed for greater quantity than the order indicates.
6. The documentation does not contain a valid standard written order (SWO).
7. Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary.
8. The medical record documentation does not contain a clinical evaluation by the treating practitioner prior to the sleep test.
9. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met.
10. Medical record documentation does not document a confirmed diagnosis of Obstructive Sleep Apnea (OSA). 

Top denial reasons for codes: B4034, B4035, B4150, B4152-B4155

1. Payment for supplies or items billed in excess of the quantity considered to be reasonable and necessary is being denied.
2. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met.
3. The claim is billed for greater quantity than the order indicates.
4. The medical record documentation does not document an impairment.
5. The documentation does not contain a valid standard written order (SWO).
6. No medical record documentation was received.
7. The medical record documentation does not specify why a standard formula cannot be used to meet the beneficiary's metabolic needs.
8. The standard written order (SWO) is missing a description of the item.
9. The medical record documentation does not establish that the beneficiary’s condition is permanent.
10. The medical record documentation does not provide justification for the use of a pump.

Top denial reason codes: E2103, A4239, A4253:

1. 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.
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. No medical record documentation was received.
4. 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).
5. Medical Records and/or beneficiary testing logs do not meet the LCD requirements for billing over-utilization amounts.
6. The documentation does not contain a valid standard written order (SWO).
7. The KX modifier was incorrectly appended. The medical record documentation supports the beneficiary is non-insulin treated.
8. The supply or accessory is denied as the base equipment is denied.
9. Claims history indicates same or similar durable medical equipment within the last 5 years.
10. Payment for this item is included in the allowance for another item provided at the same time.

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 standard written order (SWO) is missing a description of the item
3. The documentation does not contain a valid standard written order (SWO).
4. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met.
5. No medical record documentation was received.
6. The documentation is incomplete
7. The documentation submitted indicates the item(s) were returned by the beneficiary.

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

1. Documentation does not include information that supports the beneficiary had a Medicare approved transplant per LCD/Policy Article requirements.
2. No medical record documentation was received.

Top denial reasons for codes L1832-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. The medical record does not contain one of the diagnoses required by the LCD.
3. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met.
4. The medical record documentation does not support the beneficiary has had a recent injury or a surgical procedure on the knee(s).
5. The treating practitioner's order, Certificate of Medical Necessity, supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity.
6. The claim was submitted with an incorrect modifier.
7. The HCPCS procedure code on the claim is not correct for the item(s) billed.
8. No medical record documentation was received.
9. The file does not include medical records that support that the beneficiary is ambulatory.

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. The home assessment did not address the physical layout of the home, surfaces to be traversed and/or obstacles.
3. The medical record documentation does not indicate the beneficiary's mobility limitation cannot be sufficiently and safely resolved using an appropriately fitted cane or walker.
4. Neither the medical records nor supplier documentation included a home assessment.
5. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met.
6. 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 (MRADLs) and the beneficiary will be using it on a regular basis in the home.
7. 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.
8. The documentation is incomplete
9. The documentation does not contain a valid standard written order (SWO).
10. The standard written order (SWO) is missing a description of the item.

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

1. The number of units listed on the claim is above the LCD policy allowance.
2. No medical record documentation was received.
3. The claim is billed for greater quantity than the order indicates.
4. The medical record documentation does not support the beneficiary has obstructive pulmonary disease.
5. The documentation does not contain a valid standard written order (SWO).
6. The standard written order (SWO) is missing a description of the item.
7. The medical record documentation is dated after the date of service.
8. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met.
9. Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary.
10. The records indicate the drug is not being administered via a nebulizer.

Top denial reasons for codes A4431, A4434, A5081, A5057:

1. The standard written order (SWO) is missing a description of the item.
2. The claim is billed for greater quantity than the order indicates.
3. Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary.
4. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met.
5. No medical record documentation was received.
6. The medical records do not confirm that the beneficiary has a surgically created opening (stoma) to divert urine or fecal contents outside the body.

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 medical record documentation does not include a blood gas study.
5. The supplier indicates the item(s) were billed in error.
6. The medical record documentation does not contain a blood gas study performed at rest or during exercise to support a portable oxygen system.
7. The medical record documentation does not support the blood gas study was obtained within two days prior to discharge from an inpatient hospital stay.
8. The standard written order (SWO) is missing a description of the item.
9. The documentation is incomplete
10. The treating practitioner's order, Certificate of Medical Necessity, supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity.

Top denial reasons for codes L0450-L0651:

1. Medical records do not support one of the four criteria for a spinal orthosis.
2. The HCPCS procedure code on the claim is not correct for the item(s) billed.
3. No medical record documentation was received.
4. The documentation does not contain a valid standard written order (SWO).
5. The documentation is incomplete.
6. The treating practitioner's order, Certificate of Medical Necessity, supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity.
7. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met.
8. The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident.
9. The documentation does not contain a valid written order prior to delivery.

Top denial reasons for codes A6010, A6021, A6196-A6199, A6203, A6209-A6212, A6231-A6233, A6234-A6241, A6242-A6248, and 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 HCPCS code being billed.
3. Frequency of use or frequency of change is not supported by the medical records.
4. The medical records do not establish that the dressing is being used as a primary or secondary dressing or for some non-covered use (e.g. wound cleansing).
5. The standard written order (SWO) is missing a description of the item.
6. Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary.
7. 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.
8. 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.
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. The documentation does not contain a valid standard written order (SWO).

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. Documentation did not include a Statement of Certifying Physician.
3. The Statement of Certifying Physician is dated prior to a documented visit with the certifying physician.
4. The medical records do not verify that the certifying physician is managing the patient's diabetes.
5. 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.
6. 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.
7. The documentation does not contain a valid standard written order (SWO).
8. The file does not include medical records from the certifying physician.
9. Documentation did not include an in-person evaluation of the patient's feet conducted by the supplier prior to selection of the specific items.
10. The written order is signed prior to a documented visit with the prescribing practitioner.

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

1. Records do not support payment of the amount billed.
2. This item or service is denied non-covered.
3. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met.
4. The documentation does not contain a valid standard written order (SWO).
5. No medical record documentation was received.
6. The medical records from the treating practitioner do not document an impairment of urination.
7. The medical record documentation does not establish that the beneficiary's condition is permanent.
8. 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).
9. Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary.
10. The claim is billed for greater quantity than the order indicates.

Besides all the Medical Review resources, Local Coverage Determinations, and Education linked in the left navigation menu, see also:

• Documentation Checklists
• Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
• Supplier Manual Chapter 3 – Supplier Documentation