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Medical Review Quarterly Reports

Quarterly TPE Exclusion Rates:

Supplier results for all TPE reviews completed January 1 – March 31, 2026:

  • 10 Claim Pilot – 50.6% Successfully Passed
  • Round 1 – 75.4% Successfully Achieved Exclusion
  • Round 2 – 56.4% Successfully Achieved Exclusion
  • Round 3 – 66.7% Successfully Achieved Exclusion

The error rates posted below are for claims reviewed January 1 – March 31, 2026. Click to see the top denial reasons for each report:

Top denial reasons for codes L1900-L1990, L2000, L2005, L2010-L2136, L4350-L4387, L4396-L4397, L4631

  • The code on the claim isn't correct for the item billed.
  • The medical records lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
  • Medical records don't confirm that the coverage criteria have been met for an orthotic used during ambulation.

Top denial reasons for codes A7027-A7034, A7044, E0601:

  • Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary.
  • The standard written order (SWO) is missing a description of the item.
  • Documentation wasn't timely (within the preceding 12 months) to support continued need by the beneficiary.
  • Documentation doesn't include a valid in-person evaluation that meets all LCD requirements.

Top denial reasons for codes: B43034 & B4035, B4149, B4150, B4152-B4155, B4157-B4162:

  • The claim is billed for greater quantity than the order indicates.
  • The medical record doesn't specify why a standard formula cannot be used to meet the beneficiary's metabolic needs.
  • Medical records lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.

Top denial reason codes: A4233-A4236, A4239, A4253, A4256, A4258, A4259, E0607, E2103:

  • The medical record doesn't support the beneficiary had an in-person or Medicare-approved telehealth visit with their treating practitioner to assess adherence to their continuous glucose monitor (CGM) regimen and diabetes treatment plan every 6 months following the initial prescription of the CGM.
  • The medical record doesn't support the beneficiary had an in-person or Medicare-approved telehealth visit with their treating practitioner to evaluate their diabetes control and determined that criteria are met within 6 months prior to ordering the continuous glucose monitor (CGM).
  • No medical record documentation was received.

Top reasons denial for codes E0260, E0261, E0303

  • Medical records don't support the beneficiary requires frequent changes in body position and/or has an immediate need for a change in body position.
  • Medical records don't support that 1 of the 4 criteria for a fixed height hospital bed was met.
  • The treating practitioner's order, Certificate of Medical Necessity, supplier prepared statement, or the practitioner's attestation, by itself, doesn't provide sufficient documentation of medical necessity.

Top denial reasons for codes J7502, J7503, J7507, J7517, J7518, J7520, J7527:

  • Documentation doesn't include information that supports the beneficiary had a Medicare approved transplant per LCD/Policy Article requirements.
  • The documentation doesn't include a valid standard written order (SWO).
  • The claim is billed for greater quantity than the order indicates.

Top denial reasons for codes L1832, L1833, L1834, L1836, L1843, L1844, L1845, L1850, L1851, L1852, L1860, L2397:

  • The file doesn't include medical records that support an examination of knee instability and an objective description of joint laxity (for example: joint testing, anterior draw, posterior draw, valgus, or varus test) from the treating practitioner.
  • The medical record doesn't support the beneficiary had a recent injury or a surgical procedure on the knee.
  • The documentation doesn't include a valid face-to-face encounter that meets the requirements as outlined in the LCD-related Standard Documentation Requirements Article A55426.

Top denial reasons for codes A6521, A6523, A6525, A6527, A6529, A6553, A6555, A6610, A6556, A6557, A6558, A6565, A6574, A6576, A6577, A6579, A6580:

  • The item is non-covered because it is not deemed medically necessary.
  • The file doesn't include a valid Advance Beneficiary Notice.

Top denial reasons for codes K0001-K0004:

  • The medical record doesn't document that the beneficiary either has sufficient upper extremity function and other physical and mental capabilities needed to, in the home during a typical day, safely self-propel the manual wheelchair that is provided or has a caregiver who is available, willing, and able to provide assistance with the wheelchair.
  • The home assessment didn't address the physical layout of the home, surfaces to be traversed and/or obstacles.
  • The standard written order (SWO) is missing a description of the item.
  • Medical records lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.

Top denial reasons for codes J7605, J7606, J7613, J7620, J7626:

  • No medical record documentation was received.
  • The number of units listed on the claim is above the LCD policy allowance.
  • Documentation doesn't include a valid standard written order (SWO).
  • The medical record doesn't support the beneficiary has obstructive pulmonary disease.

Top denial reasons for codes E0424, E0439, E1390, E1391:

  • The medical record doesn't support the treating practitioner evaluated the results of a qualifying blood gas study performed.
  • The medical record doesn't support any of the Group I criteria.
  • The documentation doesn't include a valid standard written Order (SWO).

Top denial reasons for codes E0650, E0651, E0652:

  • Medical records lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
  • The treating practitioner's order, supplier prepared statement, or the practitioner's attestation, by itself, doesn't provide sufficient documentation of medical necessity.

Top denial reasons for codes L0450-L0651:

  • The HCPCS code on the claim is not correct for the item(s) billed.
  • No medical record documentation was received.
  • The treating practitioner's order, supplier prepared statement, or the practitioner's attestation, by itself, doesn't provide sufficient documentation of medical necessity.

Top denial reasons for codes A6010, A6021, A6196-A6199, A6203, A6209-A6212, A6231-A6233, A6234-A6241, A6242-A6248, A6251-A6256:

  • Medical records lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
  • Medical records don't establish that the dressing is being used as a primary or secondary dressing or for some non-covered use (Example: wound cleansing).
  • The monthly evaluation of the wound by the healthcare professional didn't include the type of each wound, its location, its size and depth, the amount of drainage, and any other relevant information.

Top denial reasons for codes A5500, A5512, A5513:

  • The medical record doesn't include a clinical foot evaluation either conducted by the certifying physician or approved, initialed, and dated by the certifying physician. Therefore, there is no verification that the beneficiary had one of the 6 conditions the LCD specifies must be present for coverage.
  • The file doesn't include medical records from the certifying physician.
  • Documentation didn't include an in-person evaluation of the patient's feet conducted by the supplier prior to selection of the specific items.

Top denial reasons for codes A4295, A4296, A4297, A4316, A4351, A4352, A4353, A4355:

  • Records don't support payment of the amount billed.
  • The medical record doesn't document the medical necessity for a coude (curved) tip catheter. (Example: An inability to catheterize with a straight tip catheter).
  • The documentation doesn't include a valid standard written order (SWO).
  • The medical record from the treating practitioner doesn't document an impairment of urination.

Resources

Besides all the Medical Review resources, Local Coverage Determinations, and Education linked in the left navigation menu, see also:

Updated: 05.14.2026

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