Skip to main content
Corporate
CGS Administrators, LLC

IVR: 866.238.9650 Customer Service and myCGS: 866.270.4909

2019 Quarterly Status Report – HCPCS Code J7507, J7518

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 reasons a determination was made not to pay the claim were:

Rank Reason for Denial Percent*
1 The documentation does not include a valid Detailed Written Order. Refer to Medicare Program Integrity Manual 5.2.3. 44.44%
1 The documentation does not include a valid refill request. Refer to Medicare Program Integrity Manual 5.2.8. 44.44%
3 The quantity of immunosuppressive drugs dispensed is limited to a one month supply. Quantities of immunosuppressive drugs dispensed in excess of a one month supply will be denied as not medically necessary. 25.93%
4 Documentation does not include information that supports that the beneficiary had a Medicare approved transplant per LCD/Policy Article requirements. 22.22%
5 The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. 11.11%
6 No medical record documentation was received. Refer to Medicare Program Integrity Manual 3.2.3.8. 7.41%
7 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. 3.70%

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

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved