From April 1 to June 30 of this year, the National Government Services (NGS) Jurisdiction B DME MAC Medical Review Department performed a complex review of 400 PAP claims. Of those, 268 were denied, resulting in a claim error rate of 67%; 34 claims were denied because the requested documentation wasn’t returned within the required timeframe, says NGS.
From the data collected during the second quarter, NGS says the following were the top reasons for these claims being denied as not medically necessary:
- No documentation that the beneficiary continues to use and benefit from the device for replacement following the five-year reasonable useful lifetime
- No documentation of a face-to-face evaluation by the treating physician for replacement following the five-year reasonable useful lifetime
- The beneficiary did not have a face-to-face clinical evaluation by the treating physician prior to a sleep test
- No proof of delivery from the supplier