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Appeals

Access the below appeal level related information from this page.

Submitting an Appeal

Submit claim denials for the reasons below as a Redetermination request with supporting documentation. This can be accomplished through the Noridian Medicare Portal (NMP), mail or fax.

Too Complex for Reopening and Must Be Appealed (with supporting documentation)

  • Overutilization denials (requires supporting medical records)
  • Oxygen break in service (BIS) issues
  • Medicare Secondary Payer (MSP) issues (except when Medicare is now primary)
  • Medical reviews or additional documentation requests (ADRs)
  • Change in liability - beneficiary responsibility denial request
  • Timely filing (older than one year from initial determination)
  • Recovery Auditor (RAC) related items
  • Transcutaneous Electrical Nerve Stimulators (TENS) policy
  • Duplicate denials (situational)
  • Miscellaneous and - NOC codes and claims requiring specific narratives
  • Manually priced items
  • Adding or removing modifiers:
    • Liability modifiers - EY, GA, GY, GZ, GX, KX
    • Specialty modifiers - JW, K0, K1, K2, K3, K4, KE, KK, RB, RP
    • RA
    • KG, KT
    • CR
    • CG
  • Certain HCPCS codes:
    • Common codes - E0194 (air fluidized bed), E1028 (wheelchair accessory), K0108 (wheelchair component or accessory, K0462 (loaner equipment during repair), L4210 (repair of orthotic device)
    • K1018 - K1019 (external upper limb tremor stimulator and supplies and accessories)
    • All National Drug Codes (NDCs)
  • Noncovered items/services per LCD
  • Claims with previous recoupment or refund requests
  • Claims with equipment in a non-covered status

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Last Updated Oct 23 , 2023