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 medical records do not confirm that the coverage criteria have been met for an orthotic used during ambulation.
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 records do not confirm that the coverage criteria have been met for an orthotic not used during ambulation.
5. The documentation does not contain a valid standard written order (SWO).
6. The documentation does not include a valid face-to-face encounter.
7. No medical record documentation was received.
8. 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.
9. The standard written order (SWO) is missing a description of the item.
10. The standard written order (SWO) is illegible.

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 standard written order (SWO) is missing a description of the item.
3. No medical record documentation was received.
4. The documentation does not contain a valid standard written order (SWO).
5. The supplier indicates the item was billed in error.
6. This item or service is denied non-covered. 
7. 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 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. Documentation does not include a valid in-person evaluation that meets all LCD requirements.
3. The standard written order (SWO) is missing a description of the item.
4. The documentation was not timely (within the preceding 12 months) to support continued need by the beneficiary.
5. The documentation does not contain a valid standard written order (SWO).
6. Documentation does not include a valid sleep study that meets all LCD requirements.
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. The medical record documentation did not include an in-person evaluation conducted following Medicare eligibility or the evaluation did not confirm a diagnosis of obstructive sleep apnea and continued use of the positive airway pressure device.
10. There is not a valid handwritten or electronic signature by the author of the medical record.

Top denial reasons for codes: B43034 & B4035:

1. Payment for supplies or items billed more than 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 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 feeding supply kit does not correspond with the method of enteral nutrition administration.
6. The medical record documentation does not specify why a standard formula cannot be used to meet the beneficiary's metabolic needs.
7. The medical record documentation does not show that the beneficiary's condition is permanent.
8. The claim is billed for greater quantity than the order indicates.
9. The medical record documentation does not document an impairment as defined in the local coverage determination or related policy article.
10. The medical record documentation does not justify for the use of a pump.

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. The KX modifier was incorrectly appended. The medical record documentation supports the beneficiary is non-insulin treated.
5. Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary.
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. The documentation does not contain a valid standard written order (SWO).
8. 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.
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. The supplier indicates the item was billed in error.
2. 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.

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

1. Documentation does not include information that supports that the beneficiary had a Medicare approved transplant per LCD/Policy Article requirements.
2. The claim is billed for greater quantity than the order indicates.
3. 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 (for example, joint testing, anterior draw, posterior draw, valgus/varus test) from the treating practitioner.
2. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
3. The documentation submitted is incomplete. 
4. No medical record documentation was received.
5. The medical record does not contain one of the diagnoses required by the LCD.
6. The documentation does not contain a valid standard written order (SWO).
7. The medical record documentation does not support the beneficiary has had a recent injury or a surgical procedure on the knee.
8. The medical record does not support the beneficiary is ambulatory.
9. The records do not support that the person who did the custom fitting for the orthosis has the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics such as a physician, treating practitioner, an occupational therapist, or physical therapist in compliance with all applicable Federal and State licensure and regulatory requirements.
10. The Standard Written Order (SWO) is missing a description of the item.

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 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.
3. 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.
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 medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
7. Neither the medical records nor supplier documentation included a home assessment.
8. No medical record documentation was received.
9. 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.
10. The medical record documentation does not indicate the beneficiary's mobility limitations that would establish significant impairment to participate in mobility-related activities of daily living (MRADLs) within their home.

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 documentation did not contain a valid standard written order (SWO).
4. The medical record documentation does not support the beneficiary has obstructive pulmonary disease.
5. The claim is billed for greater quantity than the order indicates.

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

1. The medical record documentation does not support the treating practitioner 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).
4. The medical record documentation does not contain a blood gas study performed at rest or during exercise to support a portable oxygen system.
5. The medical record documentation does not include a blood gas study.
6. The medical record documentation does not support the blood gas study was obtained within 2 days prior to discharge from an inpatient hospital stay.
7. The standard written order (SWO) is missing a description of the item.
8. The supplier indicates the items were billed in error.
9. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
10. The medical record documentation does not support the blood gas study was performed while the beneficiary was on 4 or more liters of oxygen per minute.

Top denial reasons for codes L0450-L0651:

1. Medical records do not support one of the four criteria for a spinal orthosis.
2. The code on the claim is not correct for the item billed.
3. The documentation does not include a valid face-to-face encounter.
4. The documentation does not contain a valid standard written order (SWO).
5. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
6. 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.
7. The item was provided prior to an inpatient hospital admission or Part A covered skilled nursing facility stay and its use began during the stay.
8. The documentation submitted indicates the item was returned by the beneficiary.

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. 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.
4. Frequency of use or frequency of change is not supported by the medical records.
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. 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 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).
9. The medical records do not show that the Alginate or other fiber gelling dressing or filler is being used to cover or fill a moderately to highly exudative full thickness wound (Stage III or Stage IV ulcer).
10. The standard written order (SWO) is missing a description of the item.

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 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. Documentation did not include a Statement of Certifying Physician.
6. 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.
7. Documentation did not include an in-person evaluation of the patient's feet conducted by the supplier prior to selection of the specific items.
8. The written order is signed prior to a documented visit with the prescribing practitioner.
9. 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.
10. The file does not include medical records from the certifying physician.

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

1. 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).
2. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
3. The medical records do not document that the beneficiary met one of the 5 additional coverage criteria for HCPCS code A4353.
4. The claim is billed for greater quantity than the order indicates.