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 items billed.
2. The medical records do not confirm that the coverage criteria have been met for an orthotic used during ambulation.
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. 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.
6. No medical record documentation was received.
7. The medical records do not confirm that the coverage criteria have been met for an orthotic not used during ambulation.
8. The claim was submitted with an incorrect modifier.
9. The documentation submitted is incomplete.
10. 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.

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

1. The standard written order (SWO) is missing a description of the item.
2. Documentation does not include a valid sleep study that meets all LCD requirements.
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. Documentation does not include a valid in-person evaluation that meets all LCD requirements.
5. The claim is billed for greater quantity than the order indicates.
6. The medical record documentation does not contain a clinical evaluation by the treating practitioner prior to the sleep test.
7. The documentation was not timely (within the preceding 12 months) to support continued need by the beneficiary.
8. The documentation does not contain a valid standard written order (SWO).
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. For the positive airway pressure (PAP) device being replaced following the 5-year reasonable useful lifetime (RUL), the documentation did not include an in-person evaluation, or the evaluation did not confirm that the beneficiary continues to use and benefit from the PAP device.

Top denial reasons for codes B4035:

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

Top denial reasons for codes A4233-A4236, A4239, A4253, A4256, A4258, A4259, E0607:

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 documentation does not contain a valid standard written order (SWO).
4. 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.
5. The documentation submitted is incomplete.
6. The medical record documentation does not support the beneficiary has diabetes.
7. The KX modifier was incorrectly appended. The medical record documentation supports the beneficiary is non-insulin treated.
8. Payment for this item is included in the allowance for another item provided at the same time.
9. 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.
10. 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 J7503, J7507, J7518, J7520, J7527:

1. Documentation does not include information that supports that the beneficiary had a Medicare approved transplant per LCD or policy article requirements.
2. No medical record documentation was received.
3. The documentation submitted is incomplete.
4. The documentation does not contain a valid standard written order (SWO).
5. The supplier indicates the item(s) were billed in error.
6. The claim is billed for greater quantity than the order indicates.

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 or 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 claim was submitted with an incorrect modifier.
5. The documentation does not contain a valid standard written order (SWO).
6. The documentation submitted is incomplete.
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 documentation does not contain a valid written order prior to delivery (WOPD).
9. The medical record documentation is illegible.
10. 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 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. The documentation does not contain a valid standard written order (SWO).
4. The supply or accessory is denied as the base equipment is denied.
5. Neither the medical records nor supplier documentation included a home assessment.
6. 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.
7. No medical record documentation was received.
8. The standard written order (SWO) is missing a description of the item.
9. The treating practitioner's order, supplier, prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity.
10. 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 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 medical record documentation does not include a blood gas study.
4. The documentation does not contain a valid standard written order (SWO).
5. The medical record documentation does not support the blood gas study was obtained within 2 days prior to discharge from an inpatient hospital stay.
6. The standard written order (SWO) is missing a description of the item.
7. The documentation submitted is incomplete.
8. The medical record documentation does not support that the qualifying gas study was performed at the time of need.
9. The standard written order (SWO) contains a treating practitioner's signature which does not comply with the Centers for Medicare & Medicaid Services signature requirements.
10. The supplier indicates the item was billed in error.

Top denial reasons for codes B4193, B4197, B4199:

1. The claim is billed for greater quantity than the order indicates.
2. The medical record documentation does not document an impairment as defined in the local coverage determination or related policy article.
3. The medical record documentation does not support the reasonable and necessary coverage criteria for parenteral nutrition have been met.
4. The standard written order (SWO) is missing a description of the item.

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 items billed.
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 include a valid written order prior to delivery (WOPD).
5. The documentation does not include a valid face-to-face encounter.
6. The documentation submitted is incomplete.
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 standard written order (SWO) is missing a description of the item.
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 documentation does not contain a valid standard written order (SWO).

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 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.
3. The medical records do not show that the Collagen dressing is being used on a full thickness wound, a wound with light to moderate exudate or on a wound that has stalled or has not progressed towards a healing goal.
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 (for example wound cleansing).
5. The item is non-covered because it is not deemed medically necessary.
6. Frequency of use or frequency of change is not supported by the medical records.
7. The size of the wound in the medical records does not support the code being billed.
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 documentation does not contain a valid standard written order (SWO).
10. Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary.

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 an in-person supplier visit at the time of delivery that assessed the fit of the shoes and inserts with the patient wearing them.
3. Documentation did not include a Statement of Certifying Physician.
4. 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.
5. The file does not include medical records from the 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. The statement of certifying physician is dated prior to a documented visit with the certifying physician.
8. Documentation did not include an in-person evaluation of the patient's feet conducted by the supplier prior to selection of the specific items.
9. The documentation does not include a valid standard written order (SWO).
10. The in-person evaluation of the patient's feet is missing a description of the abnormalities the shoes/inserts/modifications will need to accommodate.

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

1. No medical record documentation was received.
2. The claim is billed for greater quantity than the order indicates.
3. The medical records do not document that the beneficiary met one of the 5 additional coverage criteria for code A4353.
4. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
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. The medical records from the treating practitioner do not document an impairment of urination.
7. 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).
8. The documentation submitted indicates the item was returned by the beneficiary.