A denial code reads 'services not medically necessary.' What does this typically indicate and how should it be addressed?

• A. Insufficient documentation or incorrect coding; address with chart notes, rationale for the service, and correct codes to support medical necessity
• B. The patient is not eligible for the service
• C. The service was not performed
• D. The claim was not filed

Answer: (A)

This denial means the payer doesn’t see a medical justification for the service under their policies. It’s usually because the documentation doesn’t prove the service was indicated for the patient’s condition or the codes submitted don’t accurately reflect the service and diagnosis.

To address it, check the patient chart to confirm the diagnosis, signs, symptoms, and treatment plan that support why the service was needed. Make sure the CPT/HCPCS code for the service matches what was performed and that the ICD-10-CM diagnosis (or diagnoses) justify that service under the payer’s medical necessity criteria. Strengthen the submission with a clear rationale that ties the clinical findings to the indicated service, references to relevant guidelines or standard of care, prior treatments tried, and why this service is appropriate for the current condition.

Then, resubmit with corrected or more complete documentation and coding. Include the medical necessity justification in the claim or an accompanying letter, and verify whether any preauthorization or payer-specific forms are required. If allowed, consider an appeal with the payer’s process and provide all supporting records. If the service truly isn’t medically necessary, document alternative approaches and update the plan accordingly to align with coverage policies.