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

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. The documentation does not contain a valid standard written order (SWO).
4. No medical record documentation was received.

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 claim is billed for greater quantity than the order indicates.
3. Documentation does not include a valid in-person evaluation that meets all LCD requirements.
4. The standard written order (SWO) is missing a description of the item.
5. Documentation does not include a valid sleep study that meets all LCD requirements.

Top denial reasons for codes B4034,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 reasons for 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 six months prior to ordering the continuous glucose monitor (CGM).
3. No medical record documentation was received.

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 4 criteria for a fixed height hospital bed have been met.
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 standard written order (SWO) is missing a description of the item.

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 or policy article requirements.
2. The standard written order (SWO) is illegible.
3. The claim is billed for greater quantity than the order indicates.
4. The documentation is incomplete.
5. The quantity of drugs dispensed exceeds the maximum policy allowance.

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. The medical record documentation does not support the beneficiary has had a recent injury or a surgical procedure on the knee(s).
3. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met.
4. The HCPCS procedure code on the claim is not correct for the item(s) billed.

Top denial reasons 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.
2. The supplier indicates the item(s) were billed in error.

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

Top denial reasons for codes J7605, J7606, J7613, J7620, J7626, J7677:

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 E0747, E0748, E0760:

1. No medical record documentation was received.
2. 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.
3. The medical record documentation does not confirm one of the 3 criteria have been met for a spinal electrical osteogenesis stimulator.
4. The medical record documentation does not confirm one of the 3 criteria have been met for a non-spinal electrical osteogenesis stimulator.
5. 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 include a blood gas study.
2. The medical record documentation does not support the treating practitioner and has evaluated the results of a qualifying blood gas study performed.
3. The documentation does not contain a valid standard written order (SWO).
4. The medical record documentation does not support any of the Group I criteria.

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.
3. The documentation does not contain a valid standard written order (SWO).

Top denial reasons for codes E0184, E0185:

1. 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 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. The documentation does not include a valid face-to-face encounter that meets the requirements as outlined in the LCD.
4. 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 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 (e.g. wound cleansing).
3. Frequency of use or frequency of change is not supported by the medical records.
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 medical records discussing medical management of the patient’s diabetes indicate that the exam was performed by someone other than the Certifying Physician. 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. The file does not include medical records from the certifying physician.

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 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).

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