Recent Medicare claim reviews have identified several recurring documentation issues that can delay processing or result in claim denials for drug injection Prolia® (denosumab) to treat osteoporosis, every six months. The most common findings include missing provider documentation supporting medical necessity, absent DEXA scan reports, lack of T-scores or fracture risk information, and documentation that does not support administration of the drug on the billed date of service.

Providers should ensure medical records clearly support the need for Prolia treatment and include all relevant clinical documentation, such as practitioner notes, DEXA scan results, and other diagnostic information used to establish osteoporosis and fracture risk. When patients continue therapy after improvement in bone density, documentation should explain the rationale for ongoing treatment.

To help reduce additional documentation requests and denials, review records before claim submission to confirm all supporting documentation is included, and that medication administration dates match the billed date of service. Complete and thorough documentation helps demonstrate medical necessity and supports timely claim processing.