Postpayment Service-Specific Probe Results for Denosumab (Prolia) for January Through March 2021

Palmetto GBA performed service-specific postpayment probe review on HCPCS Code J0897 — Denosumab (Prolia®). This edit was set in North Carolina, South Carolina, Virginia and West Virginia. The results for the probe review, for claims processed January through March 2021, are presented here.

Cumulative Results 
A total of 139 claims were reviewed in North Carolina, South Carolina, Virginia and West Virginia combined. Four of the claims were either completely or partially denied, resulting in an overall claim denial rate of 2.88 percent. The total dollars reviewed was $113,874.14, of which $3,261.35 was denied, resulting in a charge denial rate of 2.86 percent. Overall, there were no auto-denied claims in the region. 

North Carolina Results
A total of 91 claims were reviewed, with three of the claims either completely or partially denied. This resulted in a claim denial rate of 3.30 percent. The total dollars reviewed was $72,258.02, of which $2,577.35 was denied, resulting in a charge denial rate of 3.57 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:

South Carolina Results
A total of 14 claims were reviewed, with none of the claims either completely or partially denied. This resulted in a claim denial rate of 0 percent. The total dollars reviewed was $12,722.61, of which $0 was denied, resulting in a charge denial rate of 0 percent. 

Virginia Results
No claims were reviewed in Virginia for this period.

West Virginia Results
A total of 34 claims were reviewed, with one of the claims either completely or partially denied. This results in a claim denial rate of 2.94 percent. The total dollars reviewed was $28,893.51, of which $684.00 was denied, resulting in a charge denial rate of 2.37 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:

Denial Reasons and Prevention Recommendations

5DMDP/5HMDP — Dependent Services Denied (Qualifying Service Denied Medically)

Reason for Denial
The dependent services will not be covered if the qualifying surgery has been denied. For example, the surgical procedure was denied as documentation did not support medical necessity, therefore all other charges cannot be allowed and will be denied as dependent to the medical denial of the qualifying service.

How to Avoid This Denial

• Ensure the documentation provided supports the services were reasonable and medically necessary for the treatment of the beneficiary
• Ensure all records are properly and legibly signed
• Ensure documentation supports the service(s) rendered

More Information

• 42 (CFR) Code of Federal Regulations, Section 410.32
• CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 120 (PDF)

5D920/5H920 — The Recommended Protocol Was Not Ordered and/or Followed

Reason for Denial
Medicare cannot pay for this service because one or more requirements for coverage were not met.

How to Avoid This Denial
Documentation that may be helpful to avoid future denials for this reason may include, but are not limited to, the following:

• Clear physician’s order with indication of need, dose, frequency and route 
• Date and time of associated chemotherapy, as applicable
• Relevant medical history documented prior to the DOS and signed by the physician or appropriate nonphysician provider to include:
  • Clear indication of the diagnosis
  • Clinical signs and symptoms
  • Prior treatment and response as applicable
  • Stage of treatment as applicable 
• Clear and complete documentation of administration signed by the person providing the service
• Ensure the service was provided per the coverage guidelines for the service documentation of administration 

More Information

• LCD and NCD articles on our website
• Drugs & Biologicals: Medicare Benefit Policy Manual, Publication 100-02: Chapter 15, Section 50 (PDF)
• Drugs & Biologicals: Medicare Claims Processing Manual, Publication 100-04: Chapter 17, (PDF)
• Outpatient Therapy: Medicare Benefit Policy Manual, Publication 100-02: Chapter 15, Sections 220 and 230 (PDF)
   

The Next Steps
The service-specific postpayment medical review edits for HCPCS Code J0897 — Denosumab (Prolia®) in North Carolina, South Carolina, Virginia and West Virginia will be continued based on moderate charge denial rates and medium to high impact severity errors. If significant billing aberrancies are identified, provider-specific review may be initiated.

If you are dissatisfied with a claim determination you have the right to request an appeal. Palmetto GBA encourages you to review the documentation originally submitted, and if you believe you have additional supporting documentation you may include this information with your appeal. For more information related to the appeals process please refer to the Redetermination: 1st Level Appeal Form (PDF).

Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.