Addressing Medical Necessity Denials.
                     Addressi
ng 
Medical 
Necessit
y Denials
INTRODUCTION
❏ As per Cigna’s definition Medical 
Necessity means health care services 
that a physician, exercising prudent 
clinical judgment, would provide to a 
patient. The service must be:
❏ For the purpose of evaluating, 
diagnosing, or treating an illness, 
injury, disease, or its symptoms
❏ In accordance with the generally 
accepted standards of medical billing 
practice 
❏ Clinically appropriate, in terms of 
https://www.medisysdata.com/?utm_source=social&utm_medium=blog&utm_cam
paign=Medisystmytpe, frequency, extent, site, and 
duration, and considered effective for 
the patient’s illness, injury, or disease
WhileC tohemrem aroen m Raneya dsiffoenresn tf orera sons payers 
may dMeneyd aic calali mN aesc CeOs s5i0t (y Denials
medical billing & coding services or procedures 
are not deemed a medical necessity), some of 
them may include:
● Lack of documentation necessary to support 
the length of stay
● Service provided
● Level of care
● Reason for admission
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● According to a recent survey report,  
denials management services  cost healthcare practices 
around $262 billion each year.CO 50 means that the payer 
refused to paAy dthde rcelasims binecgau Mse ethdeyi cdaidl n ot deem the 
service or procedure as medically necessary. 
● Denials receNivedc deues tsoi ltayck  Dofe mneidaiclasl necessity are 
considered as hard denials as it’s difficult to recover the lost 
payment due to this denial.CO 50 i.e., lack of 
medical billing & coding services necessary is considered as 
one of the most common denial reasons.  
● You can upgrade process flow to avoid further denials but 
you won't be able to receive insurance reimbursements 
where you are not able to prove medical billing necessity. It’s 
essential to not only understand how to solve this problem 
when this type of denial occurs, but also how to prevent it in 
the first place.
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When you receive a denial 
due to medical necessity, 
reason could be one of the 
following:
● Inpatient criteria not being met
● Inappropriate use of the emergency 
room
● Length of stay
● Inappropriate level of care
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● Why sometimes denials have generic denial 
codes and it can be tough to figure out the real 
reason it was denied. Even if you get a CO 50, 
it’s a Ggouoid iedelian teo sd ifgo dre eApperp, etaalkl itno gth e payer, 
and gMete adn iaccacul rNatee ceexpslsaintayti oDn efonr inaolns-
payment.
● Remember to not simply use the original claim 
number, but append to note it’s a corrected 
claim denials to avoid it coming back to you 
again as a duplicate claim.
● Even once you resubmit a claim that’s been 
kicked back for a CO 50 denial, be sure to follow 
up at least once a month
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● When you file appeal claims, ensure appeal letters include 
the claim number, patient, service date, provider number 
and memAbderd IDr.e Msaskein thge lMetterd toic tahel  point and ensure 
you attaNche sucpepsorstiintgy d oDcuemneinataltsion. By having everything correct the first time, you’ll prevent having the 
appeal denied.
● While CO 50 is a common denial code, your billing team 
should be better equipped to prevent and handle this 
denial. Medisys Data Solutions is a leading medical billing 
company providing complete assistance in medical billing 
and coding. We have great experience in collecting 
accurate insurance reimbursements while reducing claim 
denials. 
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● For a clinic to see an increase in 
revenue, medical billing services 
muCsto bne copltuimsizieodn. Ist h:elps to 
pinpoint potential latencies and boost 
efficiency. 
● By contracting with experienced 
service providers for medical billing, 
you may streamline your billing 
procedure. 
● They have experience with bills and 
are aware of all potential areas for 
error. 
● Making the correct outsourcing firm 
selection will undoubtedly improve 
the practice’s billing cycle and 
increase revenue. 
● What are you waiting for,
 Medisys Data Solutions is merely one 
click away!
Why choose Medisys Data 
●SHoiglhuly tqiuoalinfiesd  pfroofres sMionealds wicitha elx tBenislivlei ng 
knowledge of mSeedicravl aincde DsM?E  billing
● Easy and hassle-free onboarding for new 
customers
● Excellent control over pending, and rejected 
claims and receivables
● Communication that is smooth and open at every 
stage of the medical billing process
● Devoted, knowledgeable, and certified billing and 
coding team for your DME facility with top-notch 
claim management system
● Your questions and clarifications will be answered 
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About Us
      Medisys Data Solutions is a leading 
medical billing company providing 
complete assistance in medical billing and 
coding. We can assist you in receiving 
accurate insurance reimbursement from 
private and government payers. With our 
services like benefits verification and 
credentialing & enrollment, you can add 
more providers in your practice. To know 
more about our specialty specific medical 
billing and coding services, contact us at 
[email protected]/ +1 888-720-8884 .
   GET IN TOUCH
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        Address:
Medisys Data Solutions Inc.
8 The Green STE A, Dover, Delaware 19901,USA
Email: [email protected]
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+1 888-720-8884 
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