A prepayment review of positive airway pressure (PAP) devices for the treatment of obstructive sleep apnea (OSA)/HCPCS E0601 finds a 68% claim denial rate, according to National Government Services, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Medical Review Department.
“A selection of claims submitted from multiple suppliers were reviewed to assure that all coverage criteria and documentation requirements were met,” according to the report. “During the fourth quarter of 2012 (October 1-December 31, 2012), the DME MAC Medical Review Department processed sixty-one (61) claims that were developed for additional documentation. Two of these claims were reviewed as a reopening. Twenty-one (21) claims were allowed as billed and forty (40) claims were denied resulting in a claims error rate of 67.80%.”
The most common reasons for denial included the following:
• No face-to-face evaluation for OSA by the treating physician prior to the polysomnogram
• No documentation of instruction on the proper care and use of the device
• No face-to-face evaluation by the treating physician showing use and benefit
• No or invalid proof of delivery
• Invalid detailed written order
• No documentation that beneficiary had a valid polysomnogram prior to enrollment.