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Medical Review Quarterly Reports

Quarterly TPE Exclusion Rates:

Supplier results for all TPE reviews completed October – December 2025:

  • 10 Claim Pilot – 40% Successfully Passed
  • Round 1 – 71% Successfully Achieved Exclusion
  • Round 2 – 66.7% Successfully Achieved Exclusion
  • Round 3 – 81.8% Successfully Achieved Exclusion

The error rates posted below are for claims reviewed October – December 2025. 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

  1. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
  2. The medical records do not confirm that the coverage criteria have been met for an orthotic used during ambulation.
  3. The HCPCS procedure code on the claim is not correct for the item(s) billed.
  4. The medical records do not confirm that the coverage criteria have been met for an orthotic not used during ambulation.

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

  1. The standard written order (SWO) is missing a description of the item.
  2. Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary.
  3. Documentation does not include a valid sleep study that meets all LCD requirements.
  4. Documentation does not include a valid in-person evaluation that meets all LCD requirements.

Top denial reasons for codes: B43034, B4035

  1. The claim is billed for greater quantity than the order indicates.
  2. The medical record documentation does not specify why a standard formula cannot be used to meet the beneficiary's metabolic needs.
  3. The medical record documentation does not document an impairment as defined in the local coverage determination or related policy article.

Top denial reason codes: E2103, A4239, A4253

  1. The medical record documentation does not 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.
  2. The medical record documentation does not 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).
  3. No medical record documentation was received.

Top reasons denial for codes E0260, E0261, E0303

  1. Medical records do not support that the beneficiary requires frequent changes in body position and/or has an immediate need for a change in body position.
  2. The standard written order (SWO) is missing a description of the item.
  3. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.

Top denial reasons for codes J7503, J7507, J7518, J7520, J7527

  1. Documentation does not include information that supports the beneficiary had a Medicare approved transplant per LCD and Policy Article requirements.
  2. The claim is billed for greater quantity than the order indicates.
  3. No medical record documentation was received.

Top denial reasons for codes L1832, L1833, L1843, L1844, L1845, L1851, L1852, L2397

  1. The file does not 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/varus test) from the treating practitioner.
  2. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
  3. The medical record does not contain one of the diagnoses required by the LCD.

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

  1. The item is non-covered because it is not deemed medically necessary.
  2. The file does not contain a valid Advance Beneficiary Notice.
  3. Some or all of the Advance Beneficiary Notice is illegible.

Top denial reasons for codes K0001-K0004

  1. The medical records do not 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.
  2. The home assessment did not address the physical layout of the home, surfaces to be traversed and/or obstacles.
  3. The medical record documentation does not indicate the beneficiary's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.
  4. Neither the medical records nor supplier documentation included a home assessment.

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

  1. No medical record documentation was received.
  2. The number of units listed on the claim is above the Local Coverage Determination (LCD) policy allowance.
  3. The medical record documentation does not support the beneficiary has obstructive pulmonary disease.

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

  1. The medical record documentation does not support any of the Group I criteria.
  2. The medical record documentation does not support the treating practitioner has evaluated the results of a qualifying blood gas study performed.
  3. The documentation does not contain a valid standard written order (SWO).

Top denial reasons for codes E0650, E0651, E0652

  1. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
  2. The standard written order (SWO) is missing a description of the item.
  3. The documentation does not contain a valid standard written order (SWO).

Top denial reasons for codes L0450-L0651

  1. The code on the claim is not correct for the item billed.
  2. Medical records do not support one of the four criteria for a spinal orthosis.
  3. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.

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

  1. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
  2. The size of the wound in the medical records does not support the code being billed.
  3. Medical records show surgical dressings were applied to wounds closed with skin adhesive, which is not reasonable and necessary.

Top denial reasons for codes A5500, A5512, A5513

  1. Medical record documentation does not 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.
  2. Documentation did not include a Statement of Certifying Physician.
  3. The examination documenting the medical management of the patient's diabetes may only be performed by a doctor of osteopathy (D.O.), medical doctor (M.D.), or nurse practitioner (NP) or physician assistant (PA) practicing "incident to" the supervising physician's authority. NP or PA notes pertaining to the provision of the therapeutic shoes and inserts must be reviewed and verified by the supervising physician.

Top denial reasons for codes A4316, A4351, A4352, A4353, A4355

  1. Records do not support payment of the amount billed.
  2. The medical records from the treating practitioner do not document an impairment of urination.
  3. The submitted medical records do not document the medical necessity for a coude (curved) tip catheter. (Example: An inability to catheterize with a straight tip catheter.)

Resources

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

Updated: 02.16.2026

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