Avastin - Denial Reason Crosswalk

Published 05/04/2020

Palmetto GBA is currently updating systems to incorporate the standardized CMS reason codes and statements. In the interim, please see below list of Palmetto GBA denial codes and the corresponding CMS reason codes and statements. For more information related to CMS reason codes, please refer to the CMS website.   

Avastin — Denial Reason Crosswalk

Palmetto GBA Full Denial Code Palmetto GBA Partial Denial Code Palmetto GBA Granular Denial Reason Palmetto Denial Description CMS Reason Code CMS Statement
5D169 5H169 THE DOCUMENTATION SUBMITTED WAS NOT FOR THE CORRECT BENEFICIARY. Services Not Documented. GAI10 The documentation submitted was for the incorrect beneficiary. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2.
5D169 5H169 THE DOCUMENTATION FOR THE DATES OF SERVICE BILLED WAS NOT SUBMITTED IN THE MEDICAL RECORD. Services Not Documented. GAI11 The documentation submitted was for the incorrect dates of service. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2.
5D164 5H164 THERE WAS NO PHYSICIAN CERTIFIED DIAGNOSIS SUBMITTED IN THE MEDICAL RECORD THAT WOULD SUBSTANTIATE THE MEDICAL NEED FOR USE OF BEVACIZUMAB. Doc submitted does not support medical neccessary (provider liable). GAJ01 The submitted documentation does not support medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manuals-Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual Chapter 3 Section 3.4.1.3.
5D164 5H164 THE DOCUMENTATION SUBMITTED DOES NOT INCLUDE RELEVANT HISTORY TO SUPPORT MEDICAL NECESSITY OF DRUG ADMINISTRATION AND DOSAGE. Doc submitted does not support medical neccessary (provider liable). GAJ01  The submitted documentation does not support medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manuals-Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual Chapter 3 Section 3.4.1.3.
5D920 5H920 FOR THE DIAGNOSIS OF METASTATIC COLORECTAL CANCER (mCRC), THE RECOMMENDED DOSE OF BEVACIZUMAB FOR FIRST LINE TREATMENT OF LESS THAN OR EQUAL TO 5 MG/KG EVERY 2 WEEKS INTRAVENOUSLY IN COMBINATION WITH IFL (IRINOTECAN / FLUOROURACIL / LEUCOVORIN) CHEMOTHERAPY WAS NOT ORDERED OR FOLLOWED. The recommended protocol was not ordered and/or followed. GAJ05 The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40.
5D920 5H920 FOR THE DIAGNOSIS OF METASTATIC COLORECTAL CANCER (mCRC) THE RECOMMENDED DOSE OF BEVACIZUMAB FOR SECOND LINE TREATMENT OF LESS THAN OR EQUAL TO 10 MG/KG INTRAVENOUSLY EVERY 2 WEEKS WHEN USED IN COMBINATION WITH FOLFOX4 (FLUOROURACIL / LEUCOVORIN AND OXALIPLATIN) CHEMOTHERAPY WAS NOT ORDERED OR FOLLOWED. The recommended protocol was not ordered and/or followed. GAJ05 The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40.
5D920 5H920 FOR THE DIAGNOSIS OF METASTATIC COLORECTAL CANCER (mCRC) AFTER PROGRESSION ON A FIRST LINE BEVACIZUMAB CONTAINING REGIMEN, THE RECOMMENDED DOSE FOR BEVACIZUMAB OF LESS THAN OR EQUAL TO 5 MG/KG INTRAVENOUSLY EVERY 2 WEEKS IN COMBINATION WITH FO (FLUOROPYRIMIDINE- OXALIPLATIN) OR FI (FLUOROPYRIMIDINE- IRINOTECAN) WAS NOT ORDERED OR FOLLOWED. The recommended protocol was not ordered and/or followed. GAJ05 The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40.
5D920 5H920 FOR THE DIAGNOSIS OF METASTATIC COLORECTAL CANCER (mCRC) AFTER PROGRESSION ON A FIRST LINE AVASTIN CONTAINING REGIMEN, THE RECOMMENDED DOSE FOR BEVACIZUMAB OF LESS THAN OR EQUAL TO 7.5 MG/KG INTRAVENOUSLY EVERY 3 WEEKS IN COMBINATION WITH FO (FLUOROPYRIMIDINE- OXALIPLATIN) OR FI (FLUOROPYRIMIDINE- IRINOTECAN) WAS NOT ORDERED OR FOLLOWED. The recommended protocol was not ordered and/or followed. GAJ05 The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40.
5D920 5H920 FOR THE DIAGNOSIS OF NON-SQUAMOUS NON-SMALL CELL LUNG CANCER (NSCLC) (UNRESECTABLE, LOCALLY ADVANCED, RECURRENT OR METASTATIC), THE RECOMMENDED DOSE FOR BEVACIZUMAB OF LESS THAN OR EQUAL TO 15 MG/KG INTRAVENOUSLY EVERY 3 WEEKS IN COMBINATION WITH CARBOPLATIN AND PACILITAXEL WAS NOT ORDERED OR FOLLOWED. The recommended protocol was not ordered and/or followed. GAJ05 The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40.
5D920 5H920 FOR THE DIAGNOSIS OF METASTATIC RENAL CELL CARCINOMA, THE RECOMMENDED DOSE FOR BEVACIZUMAB OF LESS THAN OR EQUAL TO 10 MG/KG INTRAVENOUSLY EVERY 2 WEEKS IN COMBINATION WITH INTERFERON ALFA WAS NOT ORDERED OR FOLLOWED. The recommended protocol was not ordered and/or followed. GAJ05 The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40.
5D920 5H920 FOR THE DIAGNOSIS OF GLIOBLASTOMA, THE RECOMMENDED DOSAGE FOR BEVACIZUMAB OF LESS THAN OR EQUAL TO 10 MG/KG INTRAVENOUSLY EVERY 2 WEEKS WAS NOT ORDERED OR FOLLOWED. The recommended protocol was not ordered and/or followed. GAJ05 The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40.
5D920 5H920 FOR THE DIAGNOSIS OF PERSISTENT, RECURRENT OR METASTATIC CERVICAL CANCER THE RECOMMENDED PROTOCOL FOR AVASTIN OF LESS THAN OR EQUAL TO 15 MG/KG INTRAVENOUSLY IN COMBINATION WITH CISPLATIN AND PACLITAXEL ADMINISTERED EVERY 3 WEEKS (UNTIL DISEASE PROGRESSION OR UNACCEPTABLE TOXICITY) WAS NOT ORDERED OR FOLLOWED. The recommended protocol was not ordered and/or followed. GAJ05 The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40.
5D920 5H920 FOR THE DIAGNOSIS OF PERSISTENT, RECURRENT OR METASTATIC CERVICAL CANCER THE RECOMMENDED PROTOCOL FOR AVASTIN OF LESS THAN OR EQUAL TO 15 MG/KG INTRAVENOUSLY IN COMBINATION WITH TOPOTECAN AND PACLITAXEL ADMINISTERED EVERY 3 WEEKS (UNTIL DISEASE PROGRESSION OR UNACCEPTABLE TOXICITY) WAS NOT ORDERED OR FOLLOWED. The recommended protocol was not ordered and/or followed. GAJ05 The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40.
5D920 5H920 FOR THE DIAGNOSIS OF PLATINUM-RESISTANT RECURRENT EPITHELIAL OVARIAN, FALLOPIAN TUBE OR PRIMARY PERITONEAL CANCER THE RECOMMENDED PROTOCOL FOR AVASTIN OF LESS THAN OR EQUAL TO 10 MG/KG INTRAVENOUSLY EVERY 2 WEEKS WITH PACLITAXEL, PEGYLATED LIPOSOMAL DOXORUBICIN OR WEEKLY TOPOTECAN WAS NOT ORDERED OR FOLLOWED. The recommended protocol was not ordered and/or followed. GAJ05 The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40
5D920 5H920 FOR THE DIAGNOSIS OF PLATINUM-RESISTANT RECURRENT EPITHELIAL OVARIAN, FALLOPIAN TUBE OR PRIMARY PERITONEAL CANCER THE RECOMMENDED PROTOCOL FOR AVASTIN OF LESS THAN OR EQUAL TO 15 MG/KG INTRAVENOUSLY EVERY 3 WEEKS WITH TOPOTECAN GIVEN EVERY 3 WEEKS WAS NOT ORDERED OR FOLLOWED. The recommended protocol was not ordered and/or followed. GAJ05 The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40.
5D164 5H164 THE TREATMENT PROTOCOL DOCUMENTED IN THE MEDICAL RECORD SUBMITTED DOES NOT MEET COVERAGE CRITERIA. Doc submitted does not support med nec (provider liable). GAJ01  The submitted documentation does not support medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manuals-Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual Chapter 3 Section 3.4.1.3.
5D169 5H169 THERE WAS NO DOCUMENTATION OF ADMINISTRATION OF BEVACIZUMAB SUBMITTED IN THE MEDICAL RECORD. Services Not Documented. GAI04 The documentation submitted did not support the service(s) billed as being rendered. Refer to Internet-Only Manuals-Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5, A.
5D169 5H169 THE BENEFICIARY'S WEIGHT IN KILOGRAMS (KG) WAS NOT USED TO CALCULATE THE DOSE GIVEN. Services Not Documented. GAI03  Insufficient/Incomplete information. Refer to: 42 CFR 424.5(a)(6); SSA 1833(e); Medicare Program Integrity Manual IOM 100-08, Chp 3, Sec 3.2.3.8 C; Medicare Benefit Policy Manual IOM 100-02, Chp 15, Sec 220.1.2.
5D151 5H151 THE UNITS BILLED ON THE CLAIM WERE MORE THAN THE UNITS DOCUMENTED AS ORDERED / ADMINISTERED IN THE DOCUMENTATION SUBMITTED FOR REVIEW. Units Billed More Than Ordered. GAK04 The documentation submitted does not support the number of units billed. Refer to "Internet-Only Manuals, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 (coding determinations) and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23 (description of HCPCS); AMA CPT Professional coding guidelines PUB 100-4 Ch 4 Section 20.4 (UOS), 42 CFR Section 414.40, AMA HCPCS Professional coding guidelines.
5D199 5H199 Documentation does not support the claim as billed. Refer to Internet-Only Manuals, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 100-04 Medicare Claims Processing Manual, Chapter 23 Billing Error. GAK09  Documentation does not support the claim as billed. Refer to Internet-Only Manuals, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 100-04 Medicare Claims Processing Manual, Chapter 23.
5DMDP 5HMDP THE BUNDLED CHARGES OR SERVICES AND/OR SUPPLIES ASSOCIATED WITH THE ADMINISTRATION OF THE DRUG (BEVACIZUMAB) WERE DENIED. Dependent, qualifying srvc medically denied. GAJ02  Service provided is not a covered Medicare benefit. Refer to Social Security Act 1862, 42 CFR 411.15.
5DTDP 5HTDP THE BUNDLED CHARGES OR SERVICES OR SUPPLIES ASSOCIATED WITH THE ADMINISTRATION OF THE DRUG (BEVACIZUMAB) WERE DENIED. Dependent, qualifying srvc technically denied. GAJ02  Service provided is not a covered Medicare benefit. Refer to Social Security Act 1862, 42 CFR 411.15.