National Government Services, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), reported a 68% claim denial rate for PAP devices in its prepayment medical review of HCPCS E0601.
According to the DME MAC, the most common reasons for denial included:
• Returned documentation was not submitted within the time limits outlined in the Centers for Medicare & Medicaid Services Program Integrity Manual (PIM)
• No evaluation for obstructive sleep apnea by the treating physician prior to polysomnogram
• Invalid evaluation for obstructive sleep apnea by the treating physician prior to polysomnogram
• No documentation received regarding instruction on the proper care/use of the device
• Invalid documentation of a Medicare covered polysomnogram
The review took place during the third quarter of 2012.