Top denial/partial denial reasons and high-level results are listed below from each round of JH and JL Drug Injection 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 was lacking evidence of failed conservative treatment prior to drug administration.
Documentation was lacking evidence to support functional limitation of joint.
Documentation was lacking a physician order for the drug being administered.
Documentation supported a repeat series of injections initiated before six months elapsed since the prior series of injections.
Documentation did not support failure of three months conservative therapy.
Documentation did not support the use of a standardized assessment tool to assess functional limitations.
Insufficient documentation - Documentation submitted for review was insufficient to support the services as billed to Medicare. Our Medical Review makes 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:
Incident to requirements - Documentation submitted for review did not support sufficient evidence of physician supervision required to bill under the physician to Medicare.
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