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2019 Quarterly Status Report – HCPCS Code E0601, A7034, A7031, A7030, A7044

A summary report for claims reviewed between July 1, 2019 and September 30, 2019 follows: 

An analysis of the claim denials showed that the top 10 reasons a determination was made not to pay the claim were:

Rank Reason for Denial Percent*
1 Documentation does not include a valid sleep study that meets all LCD requirements. Refer to L33718. 25.54%
2 The documentation does not contain a valid detailed written order. Refer to Medicare Program Integrity Manual 5.2.3. 23.05%
3 Documentation does not include a valid face-to-face evaluation that meets all LCD requirements. Refer to L33718. 22.35%
4 Documentation does not include a valid refill request. Refer to Medicare Program Integrity Manual 5.2.8. 21.90%
5 The documentation was not timely (within the preceding 12 months) to support continued need by the beneficiary. Refer to A55426. 21.39%
6 The claim is billed for greater quantity than the detailed written order indicates. Refer to Medicare Program Integrity Manual 5.9; L33822; L33370; L33824; L33831; L33803; L33794; L33826. 6.96%
7 The order in the file is not a valid detailed written order. It is a blanket order or lacks sufficient detail to support that the item(s) delivered was the item(s) the physician ordered. Refer to Medicare Program Integrity Manual 5.2.3 & SDL A55426. 6.58%
8 The detailed written order is missing a description of the item. Refer to Medicare Program Integrity Manual 5.2.3 & SDL A55426. 5.36%
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. Refer to L33718. 3.64%
10 Medical record documentation does not document a confirmed diagnosis of OSA. Refer to L33718. 2.55%

* Total percentage will be greater than 100% because some claims were denied for multiple reasons.

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