Common Reasons for Denial

• Policy frequency limits may have been reached, per LCD

Next Step

• Review claim submitted for frequency limits listed in LCD and Policy Article and either adjust amounts because of supplier liable or appeal claim with documentation to support medical need
• Review Medically Unlikely Edit (MUE) tool for maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.
• Ensure all questions on Certificate of Medical Necessity (CMN) are qualifying (Required for dates of service prior to January 1, 2023 only)
• A Redetermination request may be submitted with all relevant supporting documentation. Noridian encourages Redeterminations/Appeals be submitted using the Noridian Medicare Portal. Review applicable Local Coverage Determination (LCD), LCD Policy Article, and Documentation Checklists prior to submitting request. Noridian encourages Redeterminations be submitted using the Noridian Medicare Portal

How to Avoid Future Denials

• For frequency guidelines, refer to applicable Local Coverage Determination (LCD), LCD Policy Article
• Review Medically Unlikely Edit (MUE) tool for maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.
• The Noridian Medicare Portal can be accessed under Same or Similar, option 2, to verify if beneficiary has had same or similar item or call the Noridian Interactive Voice Response (IVR) System for Same or Similar
• Prior to providing equipment, an Advance Beneficiary Notice of Noncoverage (ABN) may be obtained for items a supplier knows a beneficiary does not qualify for