54NCD - NCD Denial - No Diagnosis/Documentation to Support Medical Necessity

FISS Narrative
A line level reason code that indicates none of the diagnoses on claim support medical necessity of the service and no supporting documentation was provided.

Explanation and Suggestion
Service does not meet coverage requirements for a National Coverage Determination (NCD) and the provider is held liable if services are not billed correctly. The lines on the claim that lack a covered diagnosis will deny. Providers should review relevant NCDs and determine what diagnoses support medical necessity of the service. Also, examine the rules for issuance of an Advance Beneficiary Notice (ABN) and issue an ABN, when appropriate.

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