Medically necessary service or supply

The SC modifier indicates that the supplier has verified that all coverage criteria for the billed DMEPOS item have been met and that supporting documentation exists to establish medical necessity. Documentation must be available upon request.

It is recommended suppliers obtain a working knowledge of documentation requirements for specific medical policy prior to appending the SC modifier as this will help prevent unnecessary rejected or denied claims.

Correct Use

• When additional documentation is available to support the medical necessity of the item.

Incorrect Use

• Appending the SC modifier to claim(s) without verifying coverage criteria and existence of documentation.
• Appending the SC modifier where Billing and Coding guidance does not require the modifier.

Appeal Option

• Claims returned as unprocessable with remark code MA130 do not have appeal rights. These claims must be corrected and resubmitted.