5J504 - Need For Services Not Medically and Reasonable Necessary

Published 05/22/2019

The claim has been fully or partially denied as the documentation submitted for review did not support the medical necessity of the services provided.

To prevent this denial:
Documentation and tips that may be helpful to avoid future denials for this reason may include, but are not limited to, the following:

  • Submit documentation to support that services were medically necessary on an inpatient basis instead of a less intensive setting
  • Documentation should include all clinical information for the dates of service billed such as physician progress notes, physical examinations, assessments, diagnostic tests and laboratory test results, history and physical, nurse’s notes, consultations, surgical procedures, orders, discharge summary and any other documentation to support the inpatient admission
  • Include documentation of services, medication and medical interventions performed in the Emergency Department
  • For elective surgical procedures, include documentation to support the necessity of the procedure including pre-surgical interventions and outcomes

For more information refer to: