Targeted probe and educate (TPE) round results: Drugs and biologicals (HCPCS J7318-J7329, J7331-J7332)

Top denial / partial denial reasons and high-level results are listed below from each round of drugs and biologicals TPE reviews that have been conducted thus far by Medical Review. If you have questions about your individual results, please contact the nurse reviewer assigned to your review for additional information. Additional rounds of review will be utilized when the targeted topic demonstrates a continued need for review with newly identified providers.

Top denial / partial denial reasons

The most common reasons for denial or partial denials are the following:

• Medical necessity - The documentation submitted does not support medical necessity as listed in coverage requirements.
• Insufficient documentation - Insufficient documentation was provided to support the services as billed to Medicare. Medical Review makes multiple attempts to correct these error types before completion of the review. Below are the following denial reasons for insufficient documentation that we were not able to resolve:
  • Documentation submitted lacked administration method and/or dosage.
  • Documentation submitted lacked conservative treatment prior to injection and/or diagnosis.
  • Documentation submitted did not support the service billed.
  • Documentation submitted lacked treatment plans and goals, pre and post measurements.
  • Documentation submitted did not support the billed number of units and were reduced to the number of units supported.
  • Non-response to documentation request.

Round results