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2019 Quarterly Status Report – HCPCS Code J1559, J2260, J3285

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

An analysis of the claim denials from this review shows 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 refill request. Refer to Medicare Program Integrity Manual 5.2.8. 46.88%
2 The medical records do not support the LCD requirements for the external infusion pump medication have been met. Refer to L33794. 25.00%
3 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. 21.88%
4 The medical records do not confirm a diagnosis of primary immune deficiency disease as listed in the LCD. Refer to L33794. 9.38%
4 The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 3.3.2.4. 9.38%
4 The documentation does not contain a valid detailed written order. Refer to Medicare Program Integrity Manual 5.2.3. 9.38%
7 The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Claims Processing Manual. 6.25%
8 The file does not contain a valid Advance Beneficiary Notice. Refer to 100-04. 3.13%
8 A non-covered pump was billed with the external infusion medication. Per the LCD, only certain pumps can be billed with certain medications. Refer to L33794. 3.13%

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

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