The top two reasons for a positive airway pressure (PAP) device being denied as not medically necessary are as follows: 1) no face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the beneficiary for obstructive sleep apnea (OSA) or to document that the beneficiary continues to use the PAP device, and 2) no documentation that the beneficiary and/or caregiver has received instruction from the supplier of the proper use and care of the equipment.

This is according to a complex review of 313 claims from July 1, 2013 to September 30, 2013 by the National Government Services’ Medical Review Department. National Government Services is the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC). Of the 313 claims, 159 were denied, resulting in a claim error rate of 51%. A large portion of claims (51) were denied for failure of the supplier to respond in a timely manner to the request for additional documentation.

Suppliers are reminded that failure to respond to requests for additional documentation is in violation of supplier standard #28, which states the following:

“Medicare regulations (42 C.F.R ยง424.516[f]) stipulate that a supplier is required to maintain documentation for seven years from the date of service and, upon the request of the Centers for Medicare & Medicaid Services (CMS) or a Medicare contractor, provide access to that documentation. Therefore, the consequences of failure to provide records may not only be a claim denial or recoupment of a previously paid claim, but also referral to the National Supplier Clearinghouse (NSC) for possible sanctions.”