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

1. The medical records do not confirm that the coverage criteria have been met for an orthotic used during ambulation.
2. The code on the claim is not correct for the item(s) 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 contain a valid standard written order (SWO).
5. No medical record documentation was received.
6. The medical records do not confirm that the coverage criteria have been met for an orthotic not used during ambulation.
7. The claim was submitted with an incorrect modifier.
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 file does not contain a valid Advance Beneficiary Notice of Noncoverage (ABN).
10. 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.

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

1. The documentation was not timely (within the preceding 12 months) to support continued need by the beneficiary.
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. 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. 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. Medical record documentation does not document a confirmed diagnosis of OSA.
10. 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.

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

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

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

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. No medical record documentation was received.
3. Medical Records and/or beneficiary testing logs do not meet the LCD requirements for billing over-utilization amounts.
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. Payment for this item is included in the allowance for another item provided at the same time.
7. The documentation does not contain a valid standard written order (SWO).
8. The KX modifier was incorrectly appended. The medical record documentation supports the beneficiary is non-insulin treated.
9. 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).
10. The documentation is incomplete.

Top denial reasons 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. Medical records do not support that one of the four criteria for a fixed height hospital bed have been met.
4. The standard written order (SWO) is missing a description of the item.
5. The documentation does not contain a valid standard written order (SWO).
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 include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident.
8. No medical record documentation was received.
9. The medical record documentation is not authenticated (handwritten or electronic) by the author.
10. The supplier indicates the item(s) were billed in error.

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 or policy article requirements.
2. The quantity of drugs dispensed exceeds the maximum policy allowance.
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 is billed for greater quantity than the order indicates.
5. No medical record documentation was received.

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. 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 documentation is incomplete.
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(s).
8. The HCPCS procedure code on the claim is not correct for the item(s) billed.
9. The standard written order (SWO) is missing a description of the item.
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 codes K0001-K0004:

1. Neither the medical records nor supplier documentation included a home assessment.
2. 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.
3. The documentation does not contain a valid standard written order (SWO).
4. 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.
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. No medical record documentation was received.
7. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met.
8. The standard written order (SWO) is missing a description of the item.
9. 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.
10. Documentation indicates that the beneficiary has expressed an unwillingness to use the manual wheelchair in the home.

Top denial reasons for codes E0474, E0748, E0760:

1. The medical record documentation does not confirm one of the three criteria have been met for a non-spinal electrical osteogenesis stimulator.
2. The medical record documentation does not confirm all the criteria have been met for an ultrasonic osteogenesis stimulator.
3. The documentation does not include a valid face-to-face encounter that meets the requirements as outlined in the LCD-related Standard Documentation Requirements Article A55426.
4. The documentation submitted indicates the item(s) were returned by the beneficiary.
5. The medical record documentation does not confirm one of the three criteria have been met for a spinal electrical osteogenesis stimulator.
6. The documentation does not contain a valid written order prior to delivery.

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 include a blood gas study.
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 the blood gas study was obtained within two days prior to discharge from an inpatient hospital stay.
7. The supplier indicates the item(s) were billed in error.
8. The standard written order (SWO) is missing a description of the item.
9. No medical record documentation was received.
10. The medical record documentation is illegible.

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 documentation does not contain a valid standard written order (SWO).
3. The standard written order (SWO) is missing a description of the item.
4. The supplier indicates the items were billed in error.
5. The file does not contain a valid Advance Beneficiary Notice of Noncoverage.

Top denial reasons for codes L0450-L0651:

1. Medical records do not support one of the four criteria for a spinal orthosis.
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.
4. The documentation does not contain a valid standard written order (SWO).
5. The HCPCS procedure code on the claim is not correct for the item(s) billed.
6. 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.
7. The documentation is incomplete.
8. The medical record documentation is illegible.
9. The standard written order (SWO) is missing a description of the item.
10. The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident.

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 HCPCS code being billed.
3. 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).
4. The standard written order (SWO) is missing a description of the item.
5. Frequency of use or frequency of change is not supported by the medical records.
6. 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.
7. The documentation does not contain a valid standard written order (SWO).
8. The medical records do not include an evaluation of the wounds performed on a monthly basis or justification for why they could not be evaluated monthly and what other methods were used to evaluate the need for the dressings.
9. This item or service is denied non-covered.
10. 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.

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 Local Coverage Determination specifies must be present for coverage.
2. 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.
3. Documentation did not include a Statement of Certifying Physician.
4. The file does not include medical records from the certifying physician.
5. 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.
6. 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.
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 Statement of Certifying Physician is dated prior to a documented visit with the certifying physician.
9. The medical records confirm a diagnosis of peripheral neuropathy, but no evidence of callus formation is documented.
10. The medical records do not verify that the certifying physician is managing the patient's diabetes.

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 standard written order (SWO) is missing a description of the item.
3. The medical records from the treating practitioner do not document an impairment of urination.
4. The documentation submitted indicates the item was returned by the beneficiary.

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