Rituxan Reason Code Crosswalk
Published 05/04/2020
Palmetto GBA is currently updating systems to incorporate the standardized CMS reason codes and statements. In the interim, please see below list of Palmetto GBA denial codes and the corresponding CMS reason codes and statements. For more information related to CMS reason codes, please refer to the CMS website.
Rituxan — Denial Reason Crosswalk
| Palmetto GBA Full Denial Code | Palmetto GBA Partial Denial Code | Palmetto GBA Granular Denial Reason | Palmetto Denial Description | CMS Reason Code | CMS Statement |
|---|---|---|---|---|---|
| 5D169 | 5H169 | THE DOCUMENTATION SUBMITTED WAS NOT FOR THE CORRECT BENEFICIARY. | Services Not Documented | GAI10 | The documentation submitted was for the incorrect beneficiary. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2 |
| 5D169 | 5H169 | THE DOCUMENTATION FOR THE DATES OF SERVICE BILLED WAS NOT SUBMITTED IN THE MEDICAL RECORD. | Services Not Documented | GAI11 | The documentation submitted was for the incorrect dates of service. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2 |
| 5D164 | 5H164 | THERE WAS NO PHYSICIAN CERTIFIED DIAGNOSIS SUBMITTED IN THE MEDICAL RECORD THAT WOULD SUBSTANTIATE THE MEDICAL NEED FOR THE USE OF RITUXIMAB. | Doc submitted does not support med nec (provider liable) | GAJ01 | The submitted documentation does not support medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manuals-Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual Chapter 3 Section 3.4.1.3. |
| 5D164 | 5H164 | THE DOCUMENTATION SUBMITTED DOES NOT INCLUDE RELEVANT HISTORY TO SUPPORT MEDICAL NECESSITY OF DRUG ADMINISTRATION AND DOSAGE. | Doc submitted does not support med nec (provider liable) | GAJ01 | The submitted documentation does not support medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manuals-Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual Chapter 3 Section 3.4.1.3. |
| 5D169 | 5H169 | FOR THE INDICATED DIAGNOSIS OF NON-HODGKINS LYMPHOMA (NHL) THERE WAS NO DOCUMENTATION OF LYMPHOMA TYPE SUBMITTED IN THE MEDICAL RECORD. | Services Not Documented | GAI03 | Insufficient/Incomplete information. Refer to: 42 CFR 424.5(a)(6); SSA 1833(e); Medicare Program Integrity Manual IOM 100-08, Chp 3, Sec 3.2.3.8 C; Medicare Benefit Policy Manual IOM 100-02, Chp 15, Sec 220.1.2. |
| 5D920 | 5H920 | FOR THE DIAGNOSIS OF CROHNS DISEASE OR FISTULIZING CROHNS DISEASE, THE RECOMMENDED INDUCTION REGIMEN OF INFLIXIMAB LESS THAN OR EQUAL TO 5 MG/KG GIVEN INTRAVENOUSLY AT 0, 2 AND 6 WEEKS FOLLOWED BY A MAINTENANCE REGIMEN OF LESS THAN OR EQUAL TO 5 MG/KG EVERY 4-8 WEEKS THEREAFTER WAS NOT ORDERED OR FOLLOWED. | The recommended protocol was not ordered and/or followed. | GAJ05 | The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40 |
| 5D920 | 5H920 | FOR PREVIOUSLY UNTREATED FOLLICULAR, CD-20 +, B-CELL NHL, RITUXUMAB IS NOT ORDERED ON DAY 1 OF EACH CYCLE OF CVP FOR UP TO 8 DOSES. | The recommended protocol was not ordered and/or followed. | GAJ05 | The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40 |
| 5D920 | 5H920 | FOR PREVIOUSLY UNTREATED, DIFFUSE LARGE, B-CELL NHL IN COMBINATION WITH CHOP, RITUXIMAB WAS NOT ORDERED ON DAY 1 OF EACH CYCLE OF CHOP FOR UP TO 8 DOSES. | The recommended protocol was not ordered and/or followed. | GAJ05 | The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40 |
| 5D920 | 5H920 | FOR THE INDICATED DIAGNOSIS OF NON- HODGKINS LYMPHOMA (NHL), THE RECOMMENDED DOSE FOR RITUXIMAB OF LESS THAN OR EQUAL TO 375 mg/m RITUXIMAB WAS NOT ORDERED OR FOLLOWED. | The recommended protocol was not ordered and/or followed. | GAJ05 | The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40 |
| 5D920 | 5H920 | FOR RELAPSED OR REFRACTORY, LOW GRADE OR FOLLICULAR, CD20-POSITIVE, B-CELL NON HODGKINS LYMPHOMA (NHL), THE ADMINISTRATION PROTOCOL OF RITUXIMAB ONCE WEEKLY X 4 OR 8 WAS NOT ORDERED OR FOLLOWED. | The recommended protocol was not ordered and/or followed. | GAJ05 | The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40 |
| 5D920 | 5H920 | THE RECOMMENDED PROTOCOL FOR RE-TREATMENT OF RELAPSED OR REFRACTORY, LOW GRADE OR FOLLICULAR, CD20-POSITIVE B-CELL NON HODGKINS LYMPHOMA (NHL), OF RITUXIMAB ONCE WEEKLY X 4 WAS NOT ORDERED OR FOLLOWED. | The recommended protocol was not ordered and/or followed. | GAJ05 | The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40 |
| 5D920 | 5H920 | THE RECOMMENDED PROTOCOL FOR NON-PROGRESSING (INCLUDING STABLE DISEASE), LOW GRADE, CD20-POSITIVE B-CELL NON HODGKINS LYMPHOMA (NHL), AFTER THE FIRST LINE OF CVP (CYCLOPHOSPHAMIDE, VINCRISTINE, PREDNISONE) CHEMO OF RITUXIMAB ONCE WEEKLY FOR 4 DOSES AT 6 MONTHS INTERVALS TO A MAXIMUM OF 16 DOSES AFTER THE COMPLETION OF 6-8 CYCLES OF CVP CHEMO WAS NOT ORDERED OR FOLLOWED. | The recommended protocol was not ordered and/or followed. | GAJ05 | The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40 |
| 5D920 | 5H920 | FOR THE INDICATED DIAGNOSIS OF CHRONIC LYMPHOCYTIC LEUKEMIA, THE RECOMMENDED PROTOCOL FOR AN INITIAL DOSE OF RITUXIMAB LESS THAN OR EQUAL TO 375 mg/m TO BE ADMINISTERED PRIOR TO INITIATION OF FC (FLUDARABINE CYCLOSPHOSPHAMIDE) CHEMOTHERAPY WAS NOT ORDERED OR FOLLOWED. | The recommended protocol was not ordered and/or followed. | GAJ05 | The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40 |
| 5D920 | 5H920 | FOR DIAGNOSIS OF CHRONIC LYMPHOCYTIC LEUKEMIA, FOR SUBSEQUENT DOSES, THE RECOMMENDED PROTOCOL OF RITUXIMAB LESS THAN OR EQUAL TO 500 mg/m ON DAY 1 OF CYCLES 2-6 (EVERY 28 DAYS) WAS NOT ORDERED OR FOLLOWED. | The recommended protocol was not ordered and/or followed. | GAJ05 | The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40 |
| 5D920 | 5H920 | FOR THE DIAGNOSIS OF RHEUMATOID ARTHRITIS, RITUXIMAB ADMINISTERED AS LESS THAN OR EQUAL TO TWO-1000 MG INTRAVENOUS INFUSIONS, SEPARATED BY TWO WEEKS, WAS NOT ORDERED OR FOLLOWED. | The recommended protocol was not ordered and/or followed. | GAJ05 | The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40 |
| 5D920 | 5H920 | FOR THE DIAGNOSIS OF RHEUMATOID ARTHRITIS, RITUXIMAB IN COMBINATION WITH METHOTREXATE, ADMINISTERED AS LESS THAN OR EQUAL TO TWO-1000 MG INTRAVENOUS INFUSIONS, SEPARATED BY TWO WEEKS, WAS NOT ORDERED OR FOLLOWED. | The recommended protocol was not ordered and/or followed. | GAJ05 | The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40 |
| 5D920 | 5H920 | FOR DIAGNOSIS OF RHEUMATOID ARTHRITIS, FOR SUBSEQUENT DOSES, THE RECOMMENDED PROTOCOL OF RITUXIMAB EVERY 24 WEEKS OR BASED ON CLINICAL EVALUATIONS, BUT NOT SOONER THAN EVERY 16 WEEKS WAS NOT ORDERED OR FOLLOWED. | The recommended protocol was not ordered and/or followed. | GAJ05 | The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40 |
| 5D920 | 5H920 | FOR THE DIAGNOSIS WEGENERS GRANULOMATOSIS (GPA) OR MICROSCOPIC POLYANGIITIS (MPA),THE RECOMMENDED PROTOCOL OF RITUXIMAB LESS THAN OR EQUAL TO 375 mg/m ADMINISTERED ONCE A WEEK X 4 WEEKS WAS NOT ORDERED OR FOLLOWED. | The recommended protocol was not ordered and/or followed. | GAJ05 | The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40 |
| 5D164 | 5H164 | THERE WAS NO ACCEPTED OFF-LABEL DIAGNOSIS SUBMITTED IN THE MEDICAL RECORD TO SUBSTANTIATE THE MEDICAL NEED FOR THE USE OF RITUXIMAB. | Doc submitted does not support med nec (provider liable) | GAJ01 | The submitted documentation does not support medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manuals-Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual Chapter 3 Section 3.4.1.3. |
| 5D169 | 5H169 | THE RECOMMENDED DOSING SCHEDULE FOR THE COVERED OFF-LABEL USE DIAGNOSIS WAS NOT DOCUMENTED IN THE MEDICAL RECORD. | Services Not Documented | GAI03 | Insufficient/Incomplete information. Refer to: 42 CFR 424.5(a)(6); SSA 1833(e); Medicare Program Integrity Manual IOM 100-08, Chp 3, Sec 3.2.3.8 C; Medicare Benefit Policy Manual IOM 100-02, Chp 15, Sec 220.1.2. |
| 5D920 | 5H920 | THE ADMINISTRATION OF RITUXIMAB WAS NOT ORDERED TO BE ADMINISTERED WEEKLY OVER A SPAN OF 4 TO 9 WEEKS. | The recommended protocol was not ordered and/or followed. | GAJ05 | The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40 |
| 5D920 | 5H920 | THE ADMINISTRATION OF RITUXIMAB WAS NOT ORDERED TO BE ADMINISTERED LESS THAN OR EQUAL TO 21 TO 28 DAYS APART. | The recommended protocol was not ordered and/or followed. | GAJ05 | The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40 |
| 5D164 | 5H164 | THE TREATMENT PROTOCOL DOCUMENTED IN THE MEDICAL RECORD SUBMITTED DOES NOT MEET COVERAGE CRITERIA. | Doc submitted does not support med nec (provider liable) | GAJ01 | The submitted documentation does not support medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manuals-Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual Chapter 3 Section 3.4.1.3. |
| 5D169 | 5H169 | THERE WAS NO DOCUMENTATION OF ADMINISTRATION OF RITUXIMAB SUBMITTED IN THE MEDICAL RECORD. | Services Not Documented | GAI04 | The documentation submitted did not support the service(s) billed as being rendered. Refer to Internet-Only Manuals-Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5, A |
| 5D169 | 5H169 | THE BENEFICIARY'S BODY SURFACE AREA (BSA) WAS NOT SUBMITTED IN THE MEDICAL RECORD. | Services Not Documented | GAI03 | Insufficient/Incomplete information. Refer to: 42 CFR 424.5(a)(6); SSA 1833(e); Medicare Program Integrity Manual IOM 100-08, Chp 3, Sec 3.2.3.8 C; Medicare Benefit Policy Manual IOM 100-02, Chp 15, Sec 220.1.2. |
| 5D151 | 5H151 | THE UNITS BILLED ON THE CLAIM WERE MORE THAN THE UNITS DOCUMENTED AS ORDERED/ADMINISTERED IN THE DOCUMENTATION SUBMITTED FOR REVIEW. | Units Billed More Than Ordered | GAK04 | The documentation submitted does not support the number of units billed. Refer to "Internet-Only Manuals, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 (coding determinations) and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23 (description of HCPCS); AMA CPT Professional coding guidelines PUB 100-4 Ch 4 Section 20.4 (UOS), 42 CFR Section 414.40, AMA HCPCS Professional coding guidelines. |
| 5D199 | 5H199 | ALL OR PART OF THE CLAIM WAS BILLED IN ERROR. | Billing Error | GAK09 | Documentation does not support the claim as billed. Refer to Internet-Only Manuals, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 100-04 Medicare Claims Processing Manual, Chapter 23 |
| 5DMDP | 5HMDP | THE BUNDLED CHARGES OR SERVICES AND/OR SUPPLIES ASSOCIATED WITH THE ADMINISTRATION OF THE DRUG (BEVACIZUMAB) WERE DENIED. | Dependent, qualifying srvc medically denied | GAJ02 | Service provided is not a covered Medicare benefit. Refer to Social Security Act 1862, 42 CFR 411.15 |
| 5DTDP | 5HTDP | THE BUNDLED CHARGES OR SERVICES OR SUPPLIES ASSOCIATED WITH THE ADMINISTRATION OF THE DRUG (BEVACIZUMAB) WERE DENIED. | Dependent, qualifying srvc technically denied | GAJ02 | Service provided is not a covered Medicare benefit. Refer to Social Security Act 1862, 42 CFR 411.15 |