Lipid Panels: Medical Necessity Denials
Denial Reason, Reason/Remark Code(s)
- CO-50: These are non-covered services because this is not deemed a 'medical necessity' by the payer
- CPT code: 80061
CMS has established national guidelines related to lipid panels as a National Coverage Determination (NCD). The most important step you can take is to check the NCD guidelines before you submit a claim.
NCDs apply to all Medicare fee-for-service contractors and provide a uniform set of instructions for processing claims for these services. NCDs for these tests specify:
- Indications: In what circumstances is the test considered 'medically necessary'
- Limitations: In what circumstances is the test contraindicated? Are there frequency parameters for Medicare coverage?
- CPT or HCPCS codes included in the NCD
- Diagnosis codes covered by the Medicare program
- The complete NCD for lipid panels is available on the CMS website and in the CMS National Coverage Determinations manual (Pub. 100-03, Part 3, Section 190.23)
- Refer to the Medicare National Coverage Determinations Coding Policy Manual and Change Report for information regarding:
- Specific CPT and HCPCS codes included in the NCD
- Covered diagnosis codes (part of the 'laboratory edit module')
- Diagnosis codes that are 'never covered' for any laboratory NCD
- You may also download the entire lab code list from this Web page
- The covered diagnosis code list changes as often as quarterly for these NCDs; the list may differ depending upon the date of service
- The diagnosis code reported on the claim must be the most specific code available that accurately reflects the primary reason the test was ordered/performed
- The patient's medical record must support the use of the diagnosis code(s) reported on the claim
- Certain diagnosis codes are designated as 'never covered' by Medicare
- NCDs exist for other clinical laboratory tests
Advance Beneficiary Notice Information
- Be aware of coverage restrictions before you submit a claim. If Medicare will not cover the test based on the patient's condition, you may ask the patient to sign an Advance Beneficiary Notice. For more information on ABNs, refer to the Beneficiary Notices Initiative page on the CMS website.
- ABNs must be issued using the standard CMS form.
- If you have obtained a valid ABN, submit claims for this service with HCPCS modifier GA. Refer to the Palmetto GBA Modifier Lookup tool under Self Service Tools on the Palmetto GBA home page for information on HCPCS modifier GA.