The Medicare denial code CO-97 generally indicates that the claim has been denied because the service was not deemed medically necessary. This can occur for several reasons, including:
Lack of Documentation: The provider may not have submitted enough information or documentation to support that the service provided was necessary for the patient’s condition.
Insurance Coverage Policies: The service may not be covered under the patient’s specific plan due to different coverage policies regarding what is considered medically necessary.
Patient’s Condition: The patient’s medical history and current condition may not justify the necessity of the service rendered.
Preauthorization Issues: If the service required prior authorization and it was not obtained, this could lead to a denial.
- Frequency of Service: In some cases, if a similar service has been performed recently, and it is not deemed necessary to repeat it, that could lead to a denial.
When a claim receives a CO-97 denial, it usually requires the provider to review the specifics of the claim and may necessitate an appeal to provide additional information or clarification regarding the medical necessity of the services provided. The provider can also contact the payer for further clarification on the denial and the steps needed to potentially overturn it.
It’s important for healthcare providers to maintain thorough documentation and ensure that all services rendered are supported by clear evidence of medical necessity to avoid such denials.