Jurisdiction C DME MAC releases results of prepay reviews

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Friday, March 7, 2014

A claim review of the initial month of therapy for CPAP devices (E0601) for Oct. 1, 2013, to Dec. 31, 2013, showed a denial rate of 48%. In the previous quarter, the rate was 56%. The most common reason for denial: The documentation did not include a copy of a board certified document, screen print from a national certification agency, etc., that verifies that the physician who interpreted the sleep test met policy requirements (30%)…A claim review for oxygen concentrators (E1390) for Oct. 1, 2013, to Dec. 31, 2013, showed a denial rate of 68%. In the previous quarter, it was 58%. The most common reason for denial: The medical records that were received did not document that the beneficiary was seen and evaluated by the treating physician within 30 days prior to the date of initial certification (24%)…A claim review for Group 2 standard power wheelchair with Captains chair (K0823) for Oct. 1, 2013, to Dec. 31, 2013, showed a denial rate of 45%. In the previous quarter, it was 54%. The most common reason for denial: The face-to-face requirement did not provide a measurable assessment of upper extremity strength and function, so the reviewer could not rule out that the beneficiary was unable to use an optimally configured manual wheelchair (21%)…A claim review for inhalation drugs (J7605, J7606, J7613, J7620 and J7626) for Oct. 1, 2013, to Dec. 31, 2013, showed a denial rate of 56%. In the previous quarter, it was 53%. The most common reason for denial: No medical records were provided for review (46%).