What are my possible next steps with a medical necessity denial (CO-50, remark code N115) based on a Local Coverage Determination (LCD)?
Try following these suggestions: • Check the LCD and/or related Policy Article for the equipment you are billing. If a CMN/DIF is required and not submitted with the claim, send a written request to Reopenings along with the appropriate CMN/DIF. • If a required CMN/DIF was submitted and you believe the claim should not have denied, submit a redetermination request with any additional documentation to support medical necessity. • Check to see if the item you are billing is diagnosis driven (meaning the item requires a specific ICD-9 diagnosis code in order to establish medical necessity). If the wrong diagnosis code was billed by mistake, submit a request to reopenings to correct the error. • Check to see if a development (ADS) letter was received. If a development letter was received and not responded to, submit the requested documentation from the ADS letter to redeterminations. • Request a reopening for any clerical error/minor omission. If the item requires a KX modifier per the LCD
