Postpayment Service-Specific Probe Results for Prolia (Denosumab) for April through June 2021
Postpayment Service-Specific Probe Results for Prolia (Denosumab) in North Carolina, South Carolina, Virginia and West Virginia for April through June 2021
Palmetto GBA performed service-specific postpayment probe review on HCPCS Code J0897 — Prolia (Denosumab). This edit was set in North Carolina, South Carolina, Virginia and West Virginia. The results for the probe review, for claims processed April through June, 2021, are presented here.
Cumulative Results
A total of 770 claims were reviewed in North Carolina, South Carolina, Virginia and West Virginia combined, with 177 of the claims either completely or partially denied, resulting in an overall claim denial rate of 22.99 percent. The total dollars reviewed were $665,832.56, of which $96,652.82 were denied, resulting in a charge denial rate of 14.52 percent. Overall, there were a total of 183 auto-denied claims in the region.
North Carolina Results
A total of 383 claims were reviewed, with 129 of the claims either completely or partially denied. This resulted in a claim denial rate of 33.68 percent. The total dollars reviewed were $328,333.12, of which $59,844.89 were denied, resulting in a charge denial rate of 18.23 percent. The top denial reasons were identified and the number of occurrences based on dollars denied were:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
48.06% |
5D199/5H199 |
Billing Error |
62 |
43.41% |
5DMDP/5HMDP |
Dependent Services/Items Denied Because Qualifying Services Denied Medically |
56 |
3.10% |
5D164/5H164 |
No Documentation of Medical Necessity |
4 |
3.10% |
5D920/5H920 |
The Recommended Protocol Was Not Ordered and/or Followed |
4 |
2.33% |
5DTDP/5HTDP |
Services Technically Denied |
3 |
South Carolina Results
A total of 121 claims were reviewed, with 20 of the claims either completely or partially denied. This resulted in a claim denial rate of 16.53 percent. The total dollars reviewed were $102,812.99, of which $16,652.95 were denied, resulting in a charge denial rate of 16.20 percent. The top denial reasons were identified and the number of occurrences based on dollars denied were:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
85.00% |
5DMDP/5HMDP |
Dependent Services/Items Denied Because Qualifying Services Denied Medically |
17 |
10.00% |
5DTDP/5HTDP |
Services Technically Denied |
2 |
5.00% |
5D199/5H199 |
Billing Error |
1 |
Virginia Results
A total of 189 claims were reviewed, with 11 of the claims either completely or partially denied. This resulted in a claim denial rate of 5.82 percent. The total dollars reviewed were $172,141.47, of which $9,421.44 were denied, resulting in a charge denial rate of 5.47 percent. The top denial reasons were identified and the number of occurrences based on dollars denied were:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
63.64% |
5D164/5H164 |
No Documentation of Medical Necessity |
7 |
27.27% |
5DMDP/5HMDP |
Dependent Services/Items Denied Because Qualifying Services Denied Medically |
3 |
9.09% |
5D199/5H199 |
Billing Error |
1 |
West Virginia Results
A total of 77 claims were reviewed, with 17 of the claims either completely or partially denied. This resulted in a claim denial rate of 22.08 percent. The total dollars reviewed were $62,544.98, of which $10,733.54 were denied, resulting in a charge denial rate of 17.16 percent. The top denial reasons were identified and the number of occurrences based on dollars denied were:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
35.29% |
5DMDP/5HMDP |
Dependent Services/Items Denied Because Qualifying Services Denied Medically |
6 |
35.29% |
5D164/5H164 |
No Documentation of Medical Necessity |
6 |
23.53% |
5D199/5H199 |
Billing Error |
4 |
5.88% |
5D920/5H920 |
The Recommended Protocol was not Ordered and/or Followed |
1 |
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 service has been denied. For example, the service was denied as documentation did not support medical necessity, therefore all other charges associated with the service under review 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) was rendered
More Information
- 42 (CFR) Code of Federal Regulations, Section 410.32
- CMS Internet-Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 6 (PDF, 215.49 KB)
5D199/5H199 — Billing Error
Reason for Denial
The services billed were not covered because the documentation provided did not support the claim as billed by the provider.
How to Avoid This Denial
To avoid future denials for this reason:
- Check all bills for accuracy prior to submitting to Medicare
- Ensure that the documentation submitted in response to the ADR corresponds with the date that the service was rendered, and the dates of service billed
More Information
- CMS Internet-Only Manuals (IOMs), Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4 (PDF, 652.50 KB)
- CMS Internet-Only Manuals (IOMs), Pub 100-04, Medicare Claims Processing Manual
5D164/5H164 — No Documentation of Medical Necessity
Reason for Denial
This claim was denied because the documentation submitted does not support the medical necessity of the service reviewed. The records did not contain any covered condition/indication, symptomology or diagnostic results that would support the service was reasonable and necessary for the treatment of the beneficiary.
How to Avoid This Denial
- Submit all documentation related to the services billed which support the medical necessity of the services. Documentation should support:
- A covered indication or condition for the service billed
- A physician/NPP is managing the care of the covered indication or condition
- Any medical history that supports a need for the service
- Any diagnostic results or symptomology that supports a need for the services
- A legible physician or nonphysician provider (NPP) signature is required on all documentation necessary to support 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
- Social Security Act (SSA) — Section 1862(a)(1)(A)
- Local Coverage Determination (LCD) and National Coverage Determination (NCD) articles on Palmetto GBA's website
- CMS Internet-Only Manual (IOM), Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (PDF, 652.50 KB)
- CMS Medicare Learning Network (MLN) Matters article MM6698: Signature Guidelines for Medical Review Purposes
- Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices
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
- Local Coverage Determination (LCD) and National Coverage Determination (NCD) articles on Palmetto GBA's website
- Drugs & Biologicals: CMS Internet-Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50 (PDF, 1.55 MB)
- Drugs & Biologicals: CMS Internet-Only Manual (IOM), Pub 100-04, Medicare Claims Processing Manual, Chapter 17 (PDF, 318.08 KB)
- Outpatient Therapy: CMS Internet-Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 220 and 230 (PDF, 1.55 MB)
5DTDP/5HTDP — Dependent Services Denied (Qualifying Service Denied Technically)
Reason for Denial
The dependent services will not be covered if the qualifying service has been denied. For example, the service procedure was not documented, therefore all other charges cannot be allowed.
How to Avoid This Denial
- Ensure all documentation is submitted to support service was rendered
- Ensure documentation supports the claim as billed
- Ensure all documentation is properly and legibly signed
More Information
- 42 (CFR) Code of Federal Regulations, Section 410.32
- CMS Internet-Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 6 (PDF, 215.49 KB)
56900 — Auto Deny — Requested Records Not Submitted Timely
Reason for Denial
The services billed were not covered because the documentation was not received in response to the Additional Documentation Request (ADR) and therefore, we were unable to determine the medical necessity of the service billed. The provider has 45 days from the date the ADR was generated to respond with medical records. If less than 120 days after denial notification on the remittance advice, submit records to the contractor requesting records at the address listed on the original Additional Development Request (ADR) to request reopening. Do not resubmit the claim.
How to Avoid This Denial
- Be aware of the Additional Development Request (ADR) date and the need to submit medical records within 45 days of the ADR date
- Submit the medical records as soon as the Additional Development Request (ADR) is received
- Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
- Return the medical records to the address on the Additional Development Request (ADR). Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the medical review department. Fax and electronic data submissions are also accepted as indicated on the Additional Development Request (ADR).
- Gather all the information needed for the claim and submit it all at one time
- Attach a copy of the Additional Development Request (ADR) request to each individual claim
- If responding to multiple Additional Development Requests (ADRs), separate each response and attach a copy of the ADR to each individual set of medical records. Make sure each set of medical records is individually identifiable and bound securely to ensure that no documentation is detached or lost. Do not use paper clips.
- Do not mail packages C.O.D.; we cannot accept them
More Information
- CMS Internet-Only Manual (IOM), Pub 100-04, Medicare Claims Processing Manual, Chapter 34 (PDF, 109.36 KB)
- CMS Internet-Only Manual (IOM), Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.2 (PDF, 652.50 KB)
The Next Steps
The service-specific postpayment medical review edits for HCPCS Code J0897— Prolia (Denosumab) — 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, 237 KB). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.