Reason Code 5D164: Documentation Does Not Support Medical Necessity

There was no physician-certified diagnosis submitted in the medical record that would substantiate the medical need for the use of Pegfilgrastim. Documentation submitted does not support medical necessity (provider liable). The submitted documentation does not support medical necessity as listed in coverage requirements.

Additional Information

• The Social Security Act 1862(a)(1)(A)
• Internet-Only Manual 100-08 — Medicare Program Integrity Manual, Chapter 3, Sections 3.6.2.1, 3.6.2.2 (PDF)
• Internet-Only Manual 100-08 — Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.3 (PDF)