The [removed]DME MAC Jurisdiction A[/removed] has completed the widespread prepayment review of claims for continuous positive airway pressure devices (HCPCS E0601). These findings include claims processed from January 2013 through March 2013. This review continues based upon the high charge denial rate (CDR) reported from the previous quarter.
The primary reasons for denial included face-to-face clinical evaluation documentation issues with 26.1% of the denied claims missing required clinical documentation and medical records to support medical necessity; 34% of the denied claims had insufficient clinical documentation to support medical necessity and consequently did not meet the coverage criteria outlined in the PAP Local Coverage Determination.
Other reasons for denial included detailed written order issues, sleep study documentation issues, training documentation issues, and delivery issues.
This review involved prepayment complex medical review of 1,122 claims submitted by 365 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 178 (16%) of the claims. Of the 944 claims for which responses were received, 500 claims were allowed and 444 were denied/partially denied. This resulted in a claim denial rate of 47%. The total denied allowance amount (dollar amount of allowable charges for services determined to be billed in error) divided by the total allowance amount of services medically reviewed resulted in an overall charge denial rate of 67.7%.
Based on the results of this prepayment review, DME MAC A will continue to review claims billed for CPAP devices (E0601).