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Payers often reject claims because their systems or staff believe the care provided was not medically necessary. Different payers use several different denial and CARC & RARC codes to indicate medical necessity, and will often request medical records, proof of prior authorization, or both to be submitted. These documents are tedious to get, time consuming to validate, and cannot be automatically submitted. Substrate is perfect for medical necessity review automation.
Substrate makes it possible to automate the process of detecting, validating and submitting medical records or prior authorization documents without human intervention. Substrate also detects medical records requests while they're still pending and appeals them automatically before you get a denial, and tracks visits requiring prior authorization so you prevent a medical necessity denial, as well as tracks appeals so you can tell if you got paid, or see trends in real time. Some sample denial , CARC, RARC, or Closure codes are below:
LETTER IS BEING SENT. PLEASE REFER TO THE DETAIL LETTER DESCRIPTION LISTED ON THE SECONDARY LINE LEVEL CODE (LISTED JUST BELOW). ADDITIONAL INFORMATION CAN BE SUBMITTED ELECTRONICALLY BY SCROLLING TO THE BOTTOM OF THIS PAGE AND CLICKING ON VIEW OR TAKE ACTION ON YOUR CLAIM AND THEN CLICK ON ADD ATTACHMENTS.
THE CLAIM OR ENCOUNTER IS WAITING FOR INFORMATION THAT HAS ALREADY BEEN REQUESTED FROM THE PROVIDER. MEDICAL NOTE/REPORT.
AN ATTACHMENT/OTHER DOCUMENTATION IS REQUIRED TO ADJUDICATE THIS CLAIM/SERVICE.
MISSING/INCOMPLETE/INVALID PRIOR TREATMENT DOCUMENTATION
A letter has been mailed detailing additional information required to review prior to processing this claim. Submit the requested records.
If your practice experiences a high frequency of medical necessity denials, then Substrate is right for you. Some example specialities we work with (and the procedure codes they experience medical necessity denials for) are below.
- CPT 97110 – Therapeutic exercises to develop strength/endurance, range of motion, and flexibility
- Why It May Be Denied: Payers may determine ongoing or repeated sessions are not medically necessary (e.g., maintenance therapy rather than rehabilitative therapy) or request more rigorous documentation of functional improvement.
- CPT 97112 – Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception
- Why It May Be Denied: Insufficient documentation showing the need for skilled therapy or lack of measurable progress toward treatment goals.
- CPT 27447 – Arthroplasty, knee, condyle and plateau; medial and lateral compartments with or without patella resurfacing (total knee replacement)
- Why It May Be Denied: Denials can occur if there is inadequate evidence of conservative treatment failure, if the patient’s condition doesn’t meet severity thresholds, or if required pre-authorization was not obtained.
- CPT 22551 – Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2
- Why It May Be Denied: Insurers often require extensive documentation of conservative measures (e.g., physical therapy, injections) before approving spinal fusion surgery. They may also question the appropriateness of the level(s) fused.
- CPT 92928 – Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch
- Why It May Be Denied: Insurers may question necessity if there’s incomplete proof of significant coronary artery disease, lack of prior medical management, or missing supporting diagnostic results.
- CPT 93306 – Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, complete
- Why It May Be Denied: Denials may stem from insufficient justification (e.g., no clear indication of cardiac dysfunction), or payers may consider repeat echoes unnecessary within a short interval without new clinical findings.
- CPT 64483 – Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, lumbar or sacral, single level
- Why It May Be Denied: Payers often require documentation of failed conservative treatments (e.g., NSAIDs, physical therapy) before approving epidural injections and may limit frequency of injections.
- CPT 64635 – Destruction by neurolytic agent, paravertebral facet joint nerve(s), lumbar or sacral; single facet joint
- Why It May Be Denied: Radiofrequency ablation or other neurolytic procedures are frequently denied if there’s incomplete evidence of necessity (e.g., diagnostic blocks not done or insufficient duration of pain relief).
- CPT 90791 – Psychiatric Diagnostic Evaluation Services
- Why It May Be Denied: Insurers may require specific referral or pre-authorization. Denials can occur if the patient’s diagnosis or clinical notes do not support the need for a full psychiatric diagnostic evaluation.
- CPT 90837 – Psychotherapy Services and Procedures, 1 hour (53 minutes to 89 minutes)
- Why It May Be Denied: Common reasons include lack of documented progress, exceeding visit limits outlined by the payer, or inadequate treatment plan details demonstrating necessity.
- CPT 17110 – Destruction Procedures on Benign or Premalignant Lesions of the Integumentary System (other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions)
- Why It May Be Denied: May be deemed cosmetic if the documentation does not show the lesions are symptomatic, precancerous, or otherwise medically necessary to remove.
- CPT 15780 – Other Repair (Closure) Procedures on the Integumentary System
- Why It May Be Denied: Often considered cosmetic if it is primarily to improve appearance (e.g., acne scars). Payers typically require clear documentation of medical necessity (such as severe scarring impacting function).
-CPT 43644 – Laparoscopic Procedures on the Stomach
- Why It May Be Denied: Strict guidelines usually require documented weight-loss attempts, comorbidity evidence, and psychological clearance. Missing any of these can lead to denial.
- CPT 43775 – Laparoscopic Bariatric Surgery Procedures
- Why It May Be Denied: Commonly denied if the patient has not met BMI thresholds, lacks required comorbidities, or has insufficient documentation of supervised weight-loss programs.
-CPT 64615 – Destruction by Neurolytic Agent (eg, Chemical, Thermal, Electrical or Radiofrequency) Procedures on the Somatic Nerves
- Why It May Be Denied: Payers may require a trial of multiple headache therapies first, detailed headache diaries, or prior authorization. Denials often occur when documentation does not clearly meet coverage criteria for migraine frequency.
- CPT 95810 – Polysomnography; sleep staging with 4 or more additional parameters of sleep
- Why It May Be Denied: Sleep studies can be denied if a home sleep test was not attempted first (for suspected obstructive sleep apnea) or if there’s inadequate clinical evidence to justify a full lab-based polysomnogram.
- CPT 70553 – Magnetic resonance imaging (MRI) of the brain (including brain stem); without and with contrast material
- Why It May Be Denied: High-cost imaging is subject to stricter utilization review; payers may require prior authorization or deny if the clinical indication isn’t well-documented.
- CPT 73721 – Magnetic resonance imaging (MRI) of any joint of lower extremity; without contrast material
- Why It May Be Denied: May be deemed not medically necessary if conservative treatments weren’t attempted first, or if the symptoms do not match the diagnostic approach for suspected pathology.
