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Immunosuppressive Drugs Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for immunosuppressive drugs HCPCS codes J7503, J7507, J7518, J7520, and J7527 reviewed between January 1 and March 31, 2024. The error rate for this quarter is 17.39%. The top five reasons for claim denials are as follows:

Rank Reason Percent
1. The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. 28.57%
2. We did not receive any medical record documentation. 21.43%
3. The documentation does not have a valid Standard Written Order (SWO). 21.43%
4. The documentation submitted is incomplete. 21.43%
5. Documentation does not include information that supports that the beneficiary had a Medicare approved transplant per LCD/Policy Article requirements. 7.14%

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

**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to be an overall error rate for the HCPCS code or policy under medical record review.

Resources:

Updated: May 21, 2024

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