5A301, 5F301: Information Provided Does Not Support the Medical Necessity for Therapy Services

The therapy visit(s) (was/were) not covered because the documentation submitted did not support the medical necessity of these services. 

How to Prevent This Denial

Ensure that the documentation submitted supports the medical necessity of the therapy services when responding to an Additional Development Request (ADR). These services must be:

• Reasonable and necessary for the treatment of the patient’s illness or injury
• Reasonable and necessary for the restoration of maintenance of function  affected by the patient’s illness or injury
• The inherent complexity of the care is such that it can be performed safely and effectively only by or under the general supervision of a skilled therapist and require the skills of a therapist
• Include the Initial Therapy Evaluation, current therapy re-evaluation(s) for episode under review and the previous therapy re-evaluation(s) 

More Information

• 42(CFR) Code of Federal Regulations, Sections 409.33, 409.42 and 409.44
• CMS Internet-Only Manuals (IOMs), Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 40.2.1 and 40.2.2 (PDF)