“Skilled nursing services were not medically necessary” was the top reason for denials under medical review during the first three months of 2022, according to CGS, a Medicare administrative contractor (MAC) serving 15 states.
That reason alone accounted for 30% of claims denied under review.
Other top reasons for denials included:
- The initial certification was missing/incomplete/invalid; therefore, the recertification episode is denied.
- The physician certification was invalid since the required face-to-face encounter was missing/incomplete/untimely.
- The medical documentation submitted did not show that the therapy services were reasonable and necessary and at a level of complexity which requires the skills of a therapist.
- Documentation submitted does not support homebound status.