Effective for dates of service on or after June 11, 2013, contractors shall use the following messages when denying claims in excess of three for PET FDG scans for subsequent treatment strategy when the KX modifier is not included, identified by Procedure codes 78608, 78811, 78812, 78813, 78814, 78815, or 78816, modifier PS, HCPCS A9552, and the same cancer diagnosis code.
• CARC 96: “Non-Covered Charge(s). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.”
• RARC N435: “Exceeds number/frequency approved/allowed within time period without support documentation.”
• MSN 23.17: “Medicare won’t cover these services because they are not considered medically necessary.”
Spanish Version: “Medicare no cubrirá estos servicios porque no son considerados necesarios por razones médicas.”
Contractors shall use Group Code PR assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.
Contractors shall use Group Code CO assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.