Medicare Top 10 Denials 5. Medical Necessity

MRA reason code CO-50: These are non-covered services because this is not deemed a “medical necessity” by the payer.

· Remark message N115: This decision is based on a Local Medical Review Policy

(LMRP) or Local Coverage Determination (LCD). An LMRP/LCD provides a guide to assist in determining whether a particular item or service is covered. This policy is available online at http://www.cms.hhs.gov/mcd or a paper copy can be requested by contacting the contractor.


Resolution

-- Providers should familiarize themselves with National Coverage Determinations (NCDs) and LCDs.

-- Providers should identify those services and procedures they perform for which NCDs and/or LCDs are associated. Are the services medically necessary?

-- The provider should completely review the NCD and/or LCD to ensure a-- Extra time should be taken to study the utilization guidelines and documentation requirements contained in an LCD.

-- Before filing a claim to Medicare, the provider should confirm the patient’s medical documentation and records are complete. The diagnosis codes reported on the claim should correspond with the documentation.

--A valid Advance Beneficiary Notice (ABN) may be necessary when billing a service that falls under an LCD.

LCD guidelines can be found on the TrailBlazer Web site at:

http://www.trailblazerhealth.com/Tools/Local%20Coverage%20Determinations/Default.aspx?DomainID=1

Providers are encouraged to review these guidelines frequently. Medicare discourages providers from printing LCDs and using them for desk references because no LCD is ever final.


 full understanding of the policy.