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Last Modified: 12/10/2010
Location: FL, PR, USVI
Business: Part B
PR 50
These are non-covered services because this is not deemed a “medical necessity” by the payer
(MEDICARE WILL NOT PAY FOR THIS SERVICE FOR THIS CONDITION)
Resources/tips for avoiding this denial
Denial indicates the procedure code billed is incompatible with the diagnosis, for payment purposes.
• Refer to the “Active/Future/Retired LCDs” medical coverage policies for a list of procedure codes, relating to services addressed in the local coverage determination (LCD), and the diagnoses for which a service is/is not considered medically reasonable and necessary.
• Before billing a claim, you may access the Procedure to Diagnosis Lookup/Service Indication Report 
to determine if the procedure code to be billed is payable under the specific diagnosis.
to determine if the procedure code to be billed is payable under the specific diagnosis.• Note: Medicare does not cover diagnostic or screening procedures for screening purposes, such as an annual physical. This denial would be appropriate in this case.
• Respond promptly to a request for additional documentation (ADR). Failure to respond to an ADR will result in claim denials.
Resources available through the First Coast Service Options (FCSO) Medicare training Web site (www.fcsomedicaretraining.com) 
:
:• Free Web-based training (WBT) modules: Appeals Process -- Part B; Medical Documentation Request
• Recording of a FCSO webcast dated October 5, 2010 -- 10.05.10 - Avoid procedure-to-diagnosis claim denials -- Part B FL, PR, USVI located under category "2010 FCSO Medicare Training webcasts" of the FCSO Medicare training Web site , under "Learning and Metrics."
, under "Learning and Metrics."Tips to correct the denied claim
• If a payable diagnosis is indicated in the patient's encounter/service notes or record, correct the diagnosis and resubmit the claim.
• Do not resubmit an entire claim when a partial payment has been made; correct and resubmit denied lines only.
• If a claim is denied based on failure to respond to an additional documentation request, a request for a redetermination will be necessary to correct the denial. Select the correct form for your region below:
Please use your browser's back button to return to the referring page.Source: FCSO Education Action Team
