Postpayment Service-Specific Probe Results for Aflibercept (Eylea) for April through June 2021
Postpayment Service-Specific Probe Results for Aflibercept (Eylea) for April through June 2021
Palmetto GBA performed service-specific postpayment probe review on: HCPCS Codes J0178 — Aflibercept (Eylea®). 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 360 claims were reviewed with 38 of the claims either completely or partially denied, resulting in an overall claim denial rate of 10.56 percent. The total dollars reviewed was $745,028.95, of which $73,226.54 was denied, resulting in a charge denial rate of 9.83 percent. Overall, there were no auto-denied claims in the region.
North Carolina Results
A total of 122 claims were reviewed, with 15 of the claims either completely or partially denied. This resulted in a claim denial rate of 12.30 percent. The total dollars reviewed was $256,803.09, of which $28,929.35 was denied, resulting in a charge denial rate of 11.27 percent. The top denial reason were identified and the number of occurrences based on dollars denied are:
|
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
|
100.00% |
NOTML |
Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed |
15 |
South Carolina Results
A total of 43 claims were reviewed, with 11 of the claims either completely or partially denied. This resulted in a claim denial rate of 25.58 percent. The total dollars reviewed was $82,622.69, of which $21,120.67 was denied, resulting in a charge denial rate of 25.56 percent. The top denial reason was identified and the number of occurrences based on dollars denied are:
|
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
|
100.00% |
NOTML |
Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed |
11 |
Virginia Results
A total of 117 claims were reviewed, with 12 of the claims either completely or partially denied. This resulted in a claim denial rate of 10.26 percent. The total dollars reviewed was $256,033.03, of which $23,176.52 was denied, resulting in a charge denial rate of 9.05 percent. The top denial were reasons identified and the number of occurrences based on dollars denied are:
|
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
|
91.67% |
NOTML |
Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed |
11 |
|
8.33% |
NOTMN |
Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed |
1 |
West Virginia Results
A total of 78 claims were reviewed, with zero of the claims either completely or partially denied. This resulted in a claim denial rate of zero percent. The total dollars reviewed was $149,570.14, of which $0.00 was denied, resulting in a charge denial rate of zero percent. There were no denial reasons identified.
Denial Reasons and Prevention Recommendations
NOTML — Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed
- Ensure that all documentation to support medical necessity of the service billed is submitted for review. This includes original chart notes and any diagnostic, radiological or laboratory results.
- Verify that documentation to support the level of service billed is included. Please refer to our website for documentation requirements.
NOTMN — Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed
- Ensure that all documentation to support medical necessity of the service billed is submitted for review. This includes original chart notes and any diagnostic, radiological or laboratory results.
- Verify that documentation to support the level of service billed is included. Please refer to Local Coverage Determination (LCD) and National Coverage Determination (NCD) articles on Palmetto GBA's website.
The Next Steps
The service-specific targeted medical review edits for Drugs and Biological Services: HCPCS Codes J0178 — Aflibercept (Eylea®) 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 JM Redetermination: 1st Level Appeal form (PDF, 223 KB). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.