Reason Code 5H164: Documentation Does Not Support Medical Necessity

This claim was fully or partially denied because the documentation submitted for review does not support the medical necessity of some of the services billed.

To Prevent This Denial

• Submit all documentation related to the services billed which support the medical necessity of the services
• A legible signature is required on all documentation necessary to support orders and medical necessity
• Use the most appropriate ICD-10-CM codes to identify the beneficiary’s medical diagnosis

More Information

• Code of Federal Regulations, 42 CFR — Section 411.15 (PDF, 158 KB)
• Social Security Act (SSA) — Section 1862(a) (1)(A)
• Palmetto GBA Local Coverage Determination (LCD) and CMS National Coverage Determinations (NCDs)
• Code of Federal Regulations, 42 CFR — Sections 410.32 and 424.5