Noridian Administrative Services (NAS) LLC, the Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Medical Review Department, completed a widespread prepayment probe review of external breast prostheses. This review involved 95 claims of which 68 were denied, resulting in an overall error rate of 76%, according to a press release.
Primary documentation errors that resulted in denial of claims included 22% of L8030 claims in which no office notes or medical records to support medical necessity were submitted; 19% in which documentation submitted did not support medical necessity for the item requested; 17% that had invalid proof of delivery; and 14% in which no documentation was received.
Going forward, NAS will close the probe review and begin a widespread targeted review on external breast prostheses (HCPCS code L8030). The NAS concludes that suppliers should be familiar with the documentation requirements and utilization parameters as outlined in the External Breast Prostheses Local Coverage Determination L11569 and Policy Article A19833.