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Immunosuppressive Drugs Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for immunosuppressive drugs HCPCS codes J7503, J7507, J7518, J7520, and J7527 reviewed between October 1 and December 31, 2023. The error rate for this quarter is 8.57%. The top 5 reasons for claim denials are as follows:

Rank Reason Percent
1. The documentation does not contain a valid Standard Written Order (SWO). Refer to Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website. 27.27%
2. The quantity of drugs dispensed is limited to a one month supply. Quantities of drugs dispensed in excess of a one month supply will be denied as not medically necessary. 27.27%
3. The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212External PDF 18.18%
4. Documentation does not include information that supports that the beneficiary had a Medicare approved transplant per LCD/Policy Article requirements. 18.18%
5. The supplier indicates the item(s) were billed in error. 9.09%

*The total percentage will be greater than 100% because some claims were denied for multiple reasons.

**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to represent an overall error rate for the HCPCS code or policy under medical record review.

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Updated: February 2, 2024

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