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Medical Review Quarterly Reports

Quarterly TPE Exclusion Rates:

Supplier results for all TPE reviews completed April 1 – June 30, 2026:

  • 10 Claim Pilot – 45.9% Successfully Passed
  • Round 1 – 74.2% Successfully Achieved Exclusion
  • Round 2 – 53.7% Successfully Achieved Exclusion
  • Round 3 – 72.7% Successfully Achieved Exclusion

The error rates posted below are for claims reviewed April 1 – June 30, 2026. Click to see the top denial reasons for each report:

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 code on the claim is not correct for the item billed.
  3. No medical record documentation was received.
  4. The documentation does not contain a valid Standard Written Order (SWO).

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

  1. Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary.
  2. The standard written order (SWO) is missing a description of the item.
  3. Documentation does not include a valid in-person evaluation that meets all LCD requirements.
  4. The claim is billed for greater quantity than the order indicates.

Top denial reasons for codes: B43034 & B4035, B4149, B4150, B4152-B4155, B4157-B4162:

  1. The claim is billed for greater quantity than the order indicates.
  2. The medical record documentation does not specify why a standard formula cannot be used to meet the beneficiary's metabolic needs.
  3. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met.

Top denial reason codes: A4233-A4236, A4239, A4253, A4256, A4258, A4259, E0607, E2103:

  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. 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).
  3. No medical record documentation was received.

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. Medical records do not support that one of the 4 criteria for a fixed height hospital bed has been met.
  3. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met.

Top denial reasons for codes J7502, J7503, J7507, J7517, J7518, J7520, J7527:

  1. Documentation does not include information that supports the beneficiary had a Medicare approved transplant per LCD and Policy Article requirements.
  2. The standard written order (SWO) is illegible.
  3. No medical record documentation was received.

Top denial reasons for codes L1832, L1833, L1834, L1836, L1843, L1844, L1845, L1850, L1851, L1852, L1860, L2397:

  1. The file does not include medical records that support an examination of knee instability and an objective description of joint laxity (for example: joint testing, anterior draw, posterior draw, valgus or varus test) from the treating practitioner.
  2. No medical record documentation was received.
  3. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met.

Top denial reason for codes A6521, A6523, A6525, A6527, A6529, A6553, A6555, A6610, A6556, A6557, A6558, A6565, A6574, A6576, A6577, A6579, A6580:

  1. The item is non-covered because it is not deemed medically necessary.

Top denial reasons for codes K0001-K0004:

  1. The home assessment did not address the physical layout of the home, surfaces to be traversed and/or obstacles.
  2. Neither the medical records nor supplier documentation included a home assessment.
  3. 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.
  4. 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.

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 claim is billed for greater quantity than the order indicates.
  4. 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 the treating practitioner and has evaluated the results of a qualifying blood gas study performed.
  2. The medical record documentation does not support any of the Group I criteria.
  3. The documentation does not contain a valid standard written Order (SWO).

Top denial reasons for codes E0650, E0651, E0652:

  1. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met.
  2. The standard written order (SWO) is missing a description of the item.

Top denial reasons for codes L0450-L0651:

  1. The HCPCS procedure code on the claim is not correct for the item(s) billed.
  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.

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 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).
  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 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.

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. The file does not include medical records from the certifying physician.
  3. Documentation did not include an in-person evaluation of the patient's feet conducted by the supplier prior to selection of the specific items.

Top denial reasons for codes A4295, A4296, A4297, A4316, A4351, A4352, A4353, A4355:

  1. Records do not support payment of the amount billed.
  2. The documentation does not contain a valid standard written order (SWO).
  3. The medical records from the treating practitioner do not document an impairment of urination.
  4. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met.

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

Updated: 07.31.2026

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