Top denial/partial denial reasons and high-level results are listed below from each round of JH and JL cataract extraction TPE reviews that have been conducted thus far by our medical review. If you have questions about your individual results, please contact the nurse reviewer assigned to your review for additional information. Additional rounds of review will be utilized when the targeted topic demonstrates a continued need for review with newly identified providers.
The most common reasons for denial or partial denials are the following:
Medical necessity - Documentation submitted for review was lacking evidence of medical necessity for the following reasons:
Documentation lacked evidence to support the requirements in our LCD.
Documentation did not support an eye examination was performed prior to cataract surgery.
Documentation did not support ADL's were affected.
Insufficient documentation - Documentation submitted for review was insufficient to support the services as billed to Medicare. We make multiple attempts to correct these error types before completion of the review. Below is the following top denial/partial denial reason(s) for insufficient documentation that we were not able to resolve:
No response to additional documentation requests (ADRs) - Documentation was not submitted to us in a timely manner to support the services billed to Medicare.
Incorrect eye - Documentation submitted for review was for the incorrect eye.
Incorrect date of service - Documentation submitted for review did not support the date of service billed.
Billing errors - Upon receipt of the ADR request, the provider deemed the service was billed in error to Medicare.
Incorrect coding - Documentation submitted for review did not support a complex procedure was performed, therefore the claim was changed to reflect the accurate cataract procedure performed.
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