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 claim was submitted with an incorrect modifier.
6. The medical record documentation is not authenticated (handwritten or electronic) by the author.
7. 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.
8. The documentation submitted is incomplete.
9. No medical record documentation was received.
10. The order is missing a description of the item.

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 documentation does not contain a valid standard written order (SWO).
3. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
4. No medical record documentation was received.
5. The file does not contain a valid Advance Beneficiary Notice (ABN).
6. Neither the medical records nor supplier documentation included a home assessment.

Top denial reasons for 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 sleep study that meets all LCD requirements.
4. Documentation does not include a valid in-person evaluation that meets all LCD requirements.
5. The medical record documentation does not contain a clinical evaluation by the treating practitioner prior to the sleep test.
6. The documentation was not timely (within the preceding 12 months) to support continued need by the beneficiary.
7. The documentation does not contain a valid standard written order (SWO).
8. The claim is billed for greater quantity than the order indicates.
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. The clinical evaluation does not include an assessment of the beneficiary for obstructive sleep apnea.

Top denial reasons for codes B4035:

1. The feeding supply kit does not correspond with the method of enteral nutrition administration.
2. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
3. Payment for supplies or items billed in excess of the quantity considered to be reasonable and necessary is being denied.
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 claim is billed for greater quantity than the order indicates.
7. The medical record documentation does not establish that the beneficiary's condition is permanent.
8. The medical record documentation is dated after the date of service.
9. The medical record documentation is not authenticated (handwritten or electronic) by the author.
10. The supplier indicates the items were billed in error.

Top denial reasons for codes J1559, J1569, J1575:

1. The documentation does not contain a valid standard written order (SWO).
2. No medical record documentation was received.
3. The claim is billed for greater quantity than the order indicates.
4. The medical records do not confirm a diagnosis of primary immune deficiency disorder or chronic inflammatory demyelinating polyneuropathy (CIDP) that has responded to IVIG treatment.

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

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

Top denial reasons for codes E0260, E0261, E0303:

1. Medical records do not support that the beneficiary requires frequent changes in body position or has an immediate need for a change in body position.
2. Medical records do not support that one of the four criteria for a fixed height hospital bed have been 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 supplier indicates the items were billed in error.
6. The documentation submitted is incomplete.
7. Medical records do not support the beneficiary's weight is between 350 and 600 pounds and therefore qualifies for a heavy duty or extra wide hospital bed.

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

1. The documentation does not contain a valid standard written order (SWO).
2. Documentation does not include information that supports that the beneficiary had a Medicare approved transplant per LCD or policy article requirements.
3. The claim is billed for greater quantity than the order indicates.
4. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
5. The supplier indicates the items were billed in error.

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 medical record documentation is not authenticated (handwritten or electronic) by the author.
5. No medical record documentation was received.
6. The order is missing a description of the item.
7. The claim was submitted with an incorrect modifier.

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 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.
3. 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.
4. Neither the medical records nor supplier documentation included a home assessment.
5. The standard written order (SWO) is missing a description of the item.
6. The supply or accessory is denied as the base equipment is denied.
7. 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.
8. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
9. When a home assessment is based on indirectly obtained information, the supplier must verify at the time of delivery that the home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair being provided. Documentation did not include proof of this verification.
10. No medical record documentation was received.

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. The medical record documentation does not support the beneficiary has obstructive pulmonary disease.
3. The standard written order (SWO) is missing a description of the item.
4. No medical record documentation was received.
5. The documentation does not contain a valid standard written order (SWO).
6. 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 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 medical record documentation does not contain a blood gas study performed at rest or during exercise to support a portable oxygen system.
7. No medical record documentation was received.
8. The supplier indicates the item was billed in error.
9. The standard written order (SWO) is missing a description of the item.
10. The documentation submitted is incomplete.

Top denial reasons for codes L0450-L0651:

1. The code on the claim is not correct for the items billed.
2. Medical records do not support one of the four criteria for a spinal orthosis.
3. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
4. 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.
5. No medical record documentation was received.
6. The file does not contain a valid Advance Beneficiary Notice (ABN).
7. The documentation does not contain a valid standard written order (SWO).
8. The documentation does not include a valid face-to-face encounter.
9. 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.
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 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 (for example wound cleansing).
3. The monthly evaluation of the wound by the healthcare professional did not include the type of each wound, its location, it's size and depth, the amount of drainage and any other relevant information.
4. The documentation does not contain a valid standard written order (SWO).
5. 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.
6. Frequency of use or frequency of change is not supported by the medical records.
7. 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).
8. The size of the wound in the medical records does not support the code being billed.
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 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).

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. 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.
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. 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.
6. The medical records do not verify that the certifying physician is managing the patient's diabetes.
7. The medical records do not include a foot examination.
8. The supplier in-person shoe selection evaluation did not include measurements of the beneficiaries' feet.
9. The statement of certifying physician was signed more than 3 months prior to delivery of the shoes and inserts.
10. The statement of certifying physician is dated prior to a documented visit with the certifying physician.

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 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).
3. Multiple suppliers are billing for overlapping dates of service and payment has already been made for all or a portion of the medically necessary supplies for this time span.
4. The medical records from the treating practitioner do not document an impairment of urination.
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 claim is billed for greater quantity than the order indicates.
7. No medical record documentation was received.
8. According to the medical records from the treating practitioner, the impairment of urination is expected to only be temporary (less than 3 months duration) or the records do not provide sufficient information to determine whether the impairment is temporary or permanent (duration of 3 months or more).
9. The medical records do not document that the beneficiary met one of the 5 additional coverage criteria for code A4353.
10. Records do not support payment of the amount billed.