Denial Reason, Reason/Remark Code(s)
  • PR-204: This service/equipment/drug is not covered under the patient’s current benefit plan
  • PR-49: These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam
  • CPT code: 36415
Resolution/Resources
  • Procedures that are submitted to Palmetto GBA which would otherwise be considered "medically necessary" and reimbursed accordingly, are denied as "non-covered routine services" when submitted with certain diagnosis codes that indicate the services are performed in the absence of signs and symptoms
  • The Centers for Medicare & Medicaid Services (CMS) does not require providers to submit claims for services that are excluded by statute under Section 1862(a) (1) of the Social Security Act. However, if the patient (or his/her representative) believes that a service may be covered and asks that a claim be submitted, or desires a formal Medicare determination, you must file a claim for that service to effectuate the patient's right to a determination.
  • If you are submitting a non-covered service to Medicare for denial purposes, the service may be submitted with HCPCS modifier GY. This modifier lets us know that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit.
Submitting Non-covered Services for Denial Purposes
If you are submitting a non-covered service to Medicare for denial purposes, the service may be submitted with HCPCS modifier GY. This modifier lets us know that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit.
  • CMS has developed new Advance Beneficiary Notice (ABN) forms. The new forms incorporate the old Notice of Exclusion from Medicare Benefits (NEMB) language. You must use the revised CMS ABN if you are providing advance notice of non-coverage to a beneficiary. Use of the revised ABN is optional for services that are excluded from Medicare benefits. Access the revised ABN and other background information from the CMS website.
  • If you have obtained a valid ABN, submit claims for this service with HCPCS modifier GA. Refer to the Palmetto GBA Modifier Lookup tool (under Self Service Tools on home page) for information on HCPCS modifier GA.

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Provider Contact Center: 877-567-7271

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