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Tuesday, June 22, 2010

Claim denied - LACK OF MEDICAL NECESSITY ESTABLISHED

Claim denied as "LACK OF MEDICAL NECESSITY ESTABLISHED"

Description:

The payer deems the services billed not medically necessary.

Action :

The claim will be denied because the payer does not deem the   procedure for this diagnosis to be a "medical necessity." Check the Medicare newsletters for the list of covered diagnoses for a particular service. Check the Local Coverage Determination (LCD) on the respective carriers' Web site for a listing of covered diagnoses for a particular service and the appropriateness of conducting the tests. You must establish the medical necessity of common tests such as photos (both anterior segment and posterior segment) in the medical record before ordering the specific procedure. Medical records should reflect how the testing allowed you to provide a higher level of care to the patient. The testing performed should be necessary to your medical decision making, resulting in a better outcome for the patient.

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