How are services denied under Medicare when they do not meet required standards?

When services are denied under Medicare for not meeting required standards, this typically occurs through Medicare code edits. These edits are automated systems that review claims before they are processed and determine if the services provided meet the regulatory requirements and guidelines established by Medicare. If the information in the claim doesn’t align with these established codes or lacks sufficient documentation, the claim may be denied outright.

Medicare code edits are essential for maintaining compliance with both federal regulations and Medicare policies. They help ensure that only medically necessary services that meet all criteria receive reimbursement. This process protects the program from fraud and abuse and ensures that patients receive care that is in line with accepted medical standards.