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March 5, 2021

Widespread Post-Pay Service Specific Review Announcement – HCPCS Codes J7503, J7507, J7518, J7520, and J7527

CGS's Medical Review staff will be conducting a complex post-pay, service-specific medical review of HCPCS codes J7503, J7507, J7518, J7520, and J7527 (Immunosuppressive Drugs). This review will be conducted because data analysis revealed that Jurisdiction B's allowed dollars for HCPCS codes J7503, J7507, J7518, J7520, and J7527 were significantly above expected amounts. Additionally, the immunosuppressive drugs policy group ranked in the top 20 in total Comprehensive Error Rate Testing (CERT) errors.

CGS would like to remind suppliers of the importance of responding to Additional Documentation Request (ADR) letters. Authorization for the collection of this information is included in Federal Law at SSA 1833 (e) and in Federal regulation at 42 CFR 424.5(a)(6). Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Therefore, the consequences of failure to provide records may not only be a claim denial, but also referral to the National Supplier Clearinghouse (NSC).

The ADR letter will contain the following information:

  1. Preliminary dispensing order (if items were dispensed prior to obtaining a detailed written order)
  2. Physician written order
  3. Relevant supplier and medical records that verify the claim for immunosuppressive medication meets all statutory and reasonable and necessary criteria defined in the Local Coverage Determination and Policy Article
  4. Proof of the beneficiary's or caregiver's request for refill
  5. Any other pertinent records, including information related to continued use and continued medical need of the medication
  6. Copy of Advance Beneficiary Notice (ABN) if one was obtained


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