CARC 50
Narrative
These are non-covered services because they are not deemed a "medical necessity" by the payer.
RARC M64 N386
Narrative
M64: Missing/incomplete/invalid other diagnosis.
N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available by searhing the CMS website. If you do not have web access, you may contact Palmetto GBA to request a copy of the NCD.
Reason for Non-Coverage
Diagnosis Coverage.
Claim Denial vs. Rejection
Denial.
Appeal Rights
Yes.
Patient Responsibility
Yes — If GA modifier is present.
No — If GA modifier is not present.
Reference/Educational Material
- National Coverage Determination: Counseling to Prevent Tobacco Use (210.4.1)
- Preventive Services Chart
Resolution
Verify the coverage available for this service using the references above. Confirm the patient’s individual circumstances are applicable for coverage and request an appeal using Palmetto GBA’s eServices portal if you disagree with the original determination.
What to Include in The Appeal Request
Provide all documentation that supports your contention that the service meets Medicare preventive services coverage as outlined in the references above. Include any diagnosis code changes with your request.
RARC N115
Narrative
This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available by searching the CMS website. If you do not have web access, you may contact the contractor to request a copy of the LCD.
Reason for Non-Coverage
The service does not meet the medical necessity criteria outlined in the Palmetto GBA Local Coverage Determination (LCD) or associated coverage articles.
Claim Denial vs. Rejection
Denial.
Appeal Rights
Yes.
Patient Responsibility
Yes — If GA modifier is present.
No — If GA modifier is not present.
Reference/Educational Material
- MCD Search: CMS Medicare Coverage Database that lists all Palmetto GBA LCDs
- Medicare Program Integrity Manual: IOM 100-8, Chapter 13 (PDF)
Resolution
Review the LCD and any associated Coverage Article for the service billed. If after reviewing the LCD, Coverage Article (when applicable) and the patient’s Medicare records, you believe the service meets the coverage outlined in the LCD, you may request a first level appeal, a redetermination.
What to Include in The Appeal Request
Provide all documentation that supports the medical necessity of the service as outlined in the LCD and coverage article (when applicable). Include any diagnosis code changes with your request.
RARC N130
Narrative
Consult plan benefit documents/guidelines for information about restrictions for this service.
Reason for Non-Coverage
Various
- The service billed is a Medicare covered preventive service and the claim did not meet medical necessity coverage criteria
- The service denied was medically reviewed and determined that the circumstances billed on the claim did not support medical necessity
Claim Denial vs. Rejection
Denial.
Appeal Rights
Yes.
Patient Responsibility
Yes — If GA modifier is present.
No — If GA modifier is not present.
Reference/Educational Material
Resolution
Check the claim and documentation for a covered diagnosis as indicated on the LCD, NCD, or CMS Preventive Services MLN document listed above. You may request a redetermination if you feel, after reviewing coverage and medical records, that the service is medically necessary.
What to Include in The Appeal Request
Provide all documentation that supports that the service was medically necessary as outlined in the references above. Include any diagnosis code changes with your request.