Skip to main content
  • Failure to Document Medical Necessity Continues

    Palmetto GBA has released new prepayment provider-specific probe results from North Carolina, South Carolina, Virginia and West Virginia that showed most claims were denied because of documents that were incomplete or lacked medical necessity.

    In a follow-up to implementing the Targeted Probe and Educate (TPE) process for Current Procedural Terminology (CPT®) code 66984: Extracapsular Cataract Removal, that began Sept. 1, 2021; this probe reviewed claim dates between July 2022 and September 2022. 

    Denials for lack of medical necessity in chart notes as well as insufficient documentation for services billed remain at the top of probe findings.

    Claim Denial Rate By State
    North Carolina 3%
    South Carolina 10%
    Virginia 16%
    West Virginia 18%

    Percent of Total Denials

    Denial Code

    Denial Description 



    Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed 



    Documentation Requested for This Date of Service Was Not Received or Was Incomplete; Therefore, We Are Unable to Make a Reasonable and Necessary Determination as Defined Under Section 1862(a) (1) (A) of the ACT for the Service Billed and This Service Has Been Denied



    Documentation Lacks the Necessary Provider's Signature



    Documentation Received Contains an Incorrect, Incomplete or Illegible Patient Identification or Date of Service



    Claim Billed in Error per Provider  

    Help us help you meet the documentation requirements for cataract surgery. The Academy is dedicated to making sure physicians meet cataract surgery documentation guidelines and has launched a new Cataract Surgery Documentation hub at