Top Reasons for Denial for Oxygen and Oxygen Equipment Quarterly Results for Redeterminations

The Jurisdiction A, Redetermination department, completed a review of the top appealed claims for the last quarter of 2017. The top appealed policy was Oxygen and Oxygen Equipment at an appeal rate of 18.24%.

The E1390 (Oxygen Concentrator) was the top procedure code an appeal rate of 40.01%.

Top Initial Denial Reasons

  • Missing Initial Certificate of Medical Necessity (CMN)
  • Missing Recertification CMN
  • Documentation does not support coverage criteria as it is either missing or inadequate to support the medical necessity criteria of the Local Coverage Determination (LCD)

Educational Tools and Resources for Success

  • Utilize the CMN Rejection Report from your billing software company to identify claims missing CMN's.
    • Resubmit the claim with CMN attached; or,
    • Submit the CMN to Written Reopenings requesting that the CMN be loaded and denied dates of service paid
  • Have a consistent and thorough intake process that includes checking for same/similar equipment or supplies in the Noridian Medicare Portal (NMP)
  • Obtain medical records prior to dispensing to ensure the documentation exists and the beneficiary qualifies for the item(s)
  • Utilize the "Dear Physician" letters and other educational tools available from Noridian to educate physicians about the Medicare documentation requirements
  • Utilize "Documentation Checklists" to ensure complete appeal request to meet policy requirements

For complete policy details, see Oxygen and Oxygen Equipment.

Last Updated Feb 09, 2018