Primary

Reason
Code #
001
003
004
009
010
011
012
013
015
016
017
019
020
021
023
024
025
026
030
032

Primary Reason Code Description

This payment was sent to the beneficiary or their responsible party.
The Point of Pickup Address was Missing, Incomplete, or Invalid.
The provider was not certified or eligible to be paid for this procedure on this date of service.
The diagnosis code billed is inconsistant with the procedure code.
This service was included in the payment for another service received on the same day.
The provider was not certified or eligible to be paid for this procedure on this date of service.
The cost of care before and after the surgery or procedure is included in the approved amount for that
service
The service is not covered by this contractor. The facility should bill this service to the Medicare Part A
Contractor.
This service was paid previously.
This is a duplicate of a charge already submitted by another provider.
These are non-covered charges.
The procedure code is inconsistent with the modifier used or a required modifier is missing. This service does
not qualify for a HPSA/Physician Scarcity incentive payment.
This service is not covered more than once every 2 years unless the beneficiary is classified as high risk
Medicare pays for a screening Pap smear and/or screening pelvic examination only once every 2 years unless
high risk factors are present.
This is a non-covered service because it is not deemed medically necessary.
These are non-covered charges. Routine examinations and related services are not covered by Medicare.
The cost of care before and after the surgery is included in the approved amount for that service
Medicare pays for a screening Pap smear and/or screening pelvic examination only once every 2 years unless
high risk factors are present.
Service is being denied because it has not been 12 months since the beneficiary's last test or procedure of this
kind.
The provider was not certified or eligible to be paid for this procedure on this date of service.

040

This service is being denied because it has not been 24 months since the last time the patient had this service
This item is not covered because the prescription is incomplete.
The procedure or treatment has not been deemed 'proven to be effective' by the payer.
The payment is included in another service. The charges are covered under a capitation agreement or
managed care plan
Service is being denied because it has not been 48 months since the beneficiary's last test or procedure of this
kind.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.

041

This service is being denied because it has not been 10 years since the last time the patient had this service

042
045

This service is being denied because it has not been 10 years since the last time the patient had this service
This service is not covered unless the beneficiary is classified as high risk
This is a duplicate claim. Medicare has already processed this service on another claim. Please check the
status of all other claims on file for this date of service.

033
034
035
037
039

046

050
051

The Health Professional Shortage Area or physician scarcity bonus can only be paid for the professional
component of this service. Please rebill as separate professional and technical components
This service is denied because the beneficiary was in a Home Health Episode and these charges fall under
consolidated billing. Please submit these charges to the Home Health Agency.
These are non-covered charges.

053

Claim or service is denied or reduced as not furnished directly to the patient and/or not documented.

056
057

Medicare does not pay for this item or service. These are non-covered charges.
These are non-covered charges.
This procedure requires that a qualifying service be received and covered. The qualifying procedure has not
been received. Please refer to your CPT manual to determine the appropriate qualifying procedure for this
add on code.
This procedure requires that a qualifying service be received and covered. The qualifying procedure has not
been received. Please refer to your CPT manual to determine the appropriate qualifying procedure for this
add on code.
These are non-covered charges. Medicare does not pay for this item or service.
This claim overlaps inpatient stay. Rebill only those services rendered outside the inpatient stay.

048

060

061
065
066
067
068
069
070
073
074
075
076
077
078
079
080
081

082

This service is not covered since it was received as a paper submission. This claim must be filed electronically.
This is a non-covered service because it is not deemed medically necessary.
This service was denied because Medicare only covers this service once in the Beneficiary's lifetime.
The cost of care before and after the surgery or procedure is included in the approved amount for that
service.
The information provided does not support the need for this service or item. The requested records were not
received or were not received timely.
The procedure code is inconsistent with the patient's gender.
The Referring Provider NPI was Missing, Incomplete, or Invalid.
The information provided does not support the need for this service or item. Multiple physicians or assistants
are not covered in this case.
The information provided does not support the need for this service or item. The requested records were not
received or were not received timely.
The beneficiary was in a Skilled Nursing Facility on this date of service. This charge falls under consoliated
billing.
This allowance has been reduced by the amount previously paid for a related procedure.
This allowance has been reduced by the amount previously paid for a related procedure.
The beneficiary did not have Medicare Part B coverage on this date of service
Payment was adjusted as this item or service is not covered when performed or ordered by a provider of this
specialty. Payment cannot be made for an assistant surgeon in a teaching hospital unless a resident doctor
was not available.

083
084
085

086

This is a prearranged demonstration project adjustment. The prior payment was canceled as we were
subsequently notified this patient was covered by a demonstration project in this site of service. Professional
services were included in the payment made to the facility. You must contact the facility for your payment.
This item or service was denied because information required to make payment was incorrect. The days or
units of service were missing, incomplete or invalid.
For this date of service, Medicare is secondary. Please submit the claim to the primary insurer.
Medicare Part B does not cover this service because the patient was enrolled in Hospice for this date of
service. According to Medicare hospice requirements, this service is not covered because the service was
provided by a non-attending physician.

088
091

These are non-covered charges. Only one initial visit is covered per physician, group practice or provider.
Medicare does not pay for this service because it is part of another service that was performed at the same
time.
Only one pair of eyeglasses or contact lenses is covered after cataract surgery with lens implant.

095

Service is being denied because it has not been 12 months since the beneficiary's last examination of this kind.

097

Service is being denied because it has not been 12 months since the beneficiary's last examination of this kind.
Medicare does not pay for this service because it is part of another service that was performed at the same
time.
These are non covered charges because our records show the beneficiary was deported.
This item or service is not covered when performed, referred or ordered by a provider of this specialty when
the beneficiary is in a Medicare Part A covered Skilled Nursing Facility.
These are non-covered charges. Medicare does not pay for these services because the beneficiary was
incarcerated on this date of service.

087

099
102
103
104

105
106
107
108
109
110
111
112
113
114

This service was denied because Medicare only pays up to 10 hours of diabetes education training during the
initial 12-month period.
This service was denied because the beneficiary has already received the 3 hours of medical nutrition therapy
for the calander year.
This is a misdirected claim or service for a United Mine Workers of America beneficiary. Please submit the
claim to them.
This service is being denied due to the diagnosis reported.
This service was denied because the beneficiary has already received the 2 hours of follow up diabetes
education training for this calander year.
This is a payment message. Payment was reduced because the claim was received more than 1 year after the
date of service.
This service was denied because the beneficiary has already received the 2 hours of follow up medical
nutrition therapy for this calander year.
The diagnosis is inconsistent with the patient's gender. Please verify the entitlement number or name shown
on the claim.
The information provided does not support the need for this service or item. This procedure denied against a
Local Coverage Determination (LCD) Policy for not meeting medical necessity requirements.
The information provided does not support the need for this service or item. This procedure denied against a
Local Coverage Determination Policy for not meeting medical necessity requirements.

115
116
117

Payment adjusted because the payer deems the information submitted does not support this many services
according to a Local Coverage Determination policy.
Payment adjusted because the information provided does not support the need for this service or item
according to a Local Coverage Determination.
Procedure or treatment has not been deemed 'proven to be effective' by the payer according to a Local
Coverage Determination.

119

Procedure or treatment has not been deemed 'proven to be effective' by the payer. This procedure denied
against a Local Coverage Determination Policy for not meeting medical necessity requirements.
The information provided does not support the need for this service or item. The information provided was
illegible.

121

This service is being denied because it has not been 6 months since the last time the patient had this service

118

123

Payment was adjusted because the payer deems the information submitted does not support this many
services. Screening pap tests are covered only once every 24 months unless high risk factors are present.
These are non-covered charges. Payment was already made for the same or similar procedure within a set
time frame.

124

This claim/service was chosen for complex review and was denied after reviewing the medical records.

122

This claim was chosen for complex review and was denied after reviewing medical recoreds. The information
provided does not support the need for this service or item according to a Local Coverage Determination.
125
126
128
129
130
131
132
133
134

135

136

138
139

This claim was chosen for complex review and was denied after reviewing medical records because it was not
was not deemed medically necessary.
This claim was chosed for complex review and was denied after reviewing medical records because it was not
was not deemed medically necessary.
This claim was chosen for complex review and was denied after reviewing medical records because it was not
was not deemed medically necessary according to a Local Coverage Determination.
This claim was chosen for complex review and was denied after reviewing medical records because the
records do not support this many services.
Claim or service lacks information which is needed for the claim to be processed.
This item or service cannot be paid unless the provider accepts assignment.
The Referring Provider NPI was Missing, Incomplete, or Invalid.
This service is denied when performed or billed by this type of provider
This claim was chosen for complex review and was denied after reviewing medical records. The information
provided does not support the need for this service or item according to a Local Coverage Determination.
Since the patient is covered under an Employer Group Health Plan, and the plan has denied their claim,
Medicare benefits are being paid on the condition that, if payment is received from the employer plan,
Medicare must be repaid.
This claim was chosen for complex review and was denied after reviewing medical records. The information
provided does not support the need for this service or item according to a Local Coverage Determination.
This claim was chosen for complex review and was denied after reviewing medical records because it was not
deemed 'proven to be effective' by the payer.

140
141
142
143

145
146

147
148
150
152

A screening mammogram is covered only once for women under age 40.
This claim was chosen for complex review and was denied after reviewing medical records because it was not
deemed 'proven to be effective' by the payer.
This claim was chosed for complex review and was denied after reviewing medical records because it was not
deemed 'proven to be effective' by the payer.
The procedure code is inconsistent with the patient's age. Screening mammography is not covered for women
under 35 years of age.
Payment adjusted because the payer deems the information submitted does not support this many services.
Medicare will only pay for a screening mammogram once every 12 months unless high risk factors are
present.
Payment adjusted because the payer deems the information submitted does not support this many services.
It has not been 12 months since the beneficiary's last test or procedure of this kind.
This claim was chosen for complex review and was denied after reviewing medical records. The information
provided does not support the need for this service or item according to a Local Coverage Determination.
This is a duplicate claim. Medicare has already processed this service on another claim. Please check the
status of all other claims on file for this date of service.
The information provided does not support the need for this item or service.
The information provided does not support the need for this service or item. The requested records were not
received or were not received timely.
The information provided does not support the need for this many services or items within this period of
time.

153
154
159
161
162
163
164
165

166
170
171
172

173
174

Payment adjusted because the payer deems the information submitted does not support this many services.
This item or service was denied because information required to make payment was incorrect according to a
Local Coverage Determination .
These are non-covered charges. This immunization and/or preventive care is not covered by medicare.
This is a non-covered service. Routine examinations and related services are not covered by Medicare.
The procedure code modifier combination was invalid
The procedure code submitted was adjusted because the documentation submitted does not support the
level of service billed according to a Local Coverage Determination .
The procedure code is inconsistent with the modifier used or a required modifier is missing.
This procedure requires that a qualifying service be received and covered. The qualifying procedure has not
been received. Please refer to your CPT manual to determine the appropriate qualifying procedure for this
add on code.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.
The provider was not certified or eligible to be paid for this procedure on this date of service.
The claim or service lacks information which is needed for processing. Please verify the information
submitted on your claim.
This procedure requires that a qualifying service be received and covered. The qualifying procedure has not
been received. Please refer to your CPT manual to determine the appropriate qualifying procedure for this
add on code.
The procedure code submitted was adjusted because the documentation submitted does not support the
level of service billed according to a Local Coverage Determination .

175
176
177
178
179
180
182
183
186
187
188
190

This procedure requires that a qualifying service be received and covered. The qualifying procedure has not
been received. Please refer to your CPT manual to determine the appropriate qualifying procedure for this
add on code.
This is a payment message. Payment was reduced because the claim was received more than 1 year after the
date of service.
These are non-covered charges. The procedure code reported is for informational purposes only.
Payment is included in another service received on the same day.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.
Claim or service lacks information which is needed for the claim to be processed
Services or items not approved by the Food and Drug Administration are not covered.
This is a non-covered service.
This claim was chosen for complex review and was denied after reviewing medical records because the
records do not support this many services.
This claim was chosen for complex review and was denied after reviewing medical records because the
records do not support this many services.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.

205

Payment for charges adjusted. Charges are covered under a capitation agreement or managed care plan.
This service was denied because the procedure code and modifier were invalid on the date of service.
Payment was adjusted because the beneficiary was not lawfully present in the United States on this date of
service.
This is an add-on procedure code and the primary procedure was not billed or was not billed on the same
claim for the same date of service.
This is a non-covered service.
The information provided does not support the need for this service or item. The documentation submitted
does not match the claim.
This is a non-covered service because it is not deemed a medical necessity because multiple physicians or
assistants are not covered in this case.
The benefit maximum for this time period has been reached.
Medicare does not pay for this equipment or item.
This item or service cannot be paid unless the provider accepts assignment.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.

206

This service is being denied because it has not been 6 months since the last time the patient had this service

207

This service is being denied because it has not been 6 months since the last time the patient had this service
Claim or service denied because the submitted authorization number is missing, invalid or does not apply to
the billed services.
Paid at the regular rate as you did not submit documentation to justify the modified procedure code.
The Referring Provider NPI was Missing, Incomplete, or Invalid.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.

191
192
193
196
197
198
199
202
203
204

209
211
212
214

217
218
219
223
225
226
228
229
231
235
239
240
245
255
257
258
259
262
265
266
275
280
281
282
283
284
285
287
288
290
294
295
296
297
298
300
302
304

The Medicare # or name was Missing, Incomplete, or Invalid.

This item or service was denied because information required to make a payment was missing.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.
The claim or service lacks information which is needed for processing.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.
The date range does not match the units billed.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.
The diagnosis code on the claim needs to be more specific. You are required to code to the highest level of
specificity.
The procedure code is inconsistent with the modifier used or a required modifier is missing.
The Date Last Seen and / or the Referring Provider NPI was Missing, Incomplete, or Invalid.
The Group Practice was Missing, Incomplete, or Invalid.
The place of service was Missing, Incomplete, or Invalid.
The Initial Treatment Date was Missing, Incomplete, or Invalid.
The claim did not indicate whether or not Medicare was the Primary insurance.
The information provided does not support the need for this service or item.
The information provided does not support the need for this service or item.
The patient cannot be identified as a Medicare Beneficiary
The provider was not certified or eligible to be paid for this procedure on this date of service.
Payment was made to the patient or their responsible party.
This payment was sent to the beneficiary or their responsible party.
The CLIA certification number was Missing, Incomplete, or Invalid.
This claim information is also being forwarded to the patient's supplemental insurer.
The claim is Missing plan information for other insurance
This is a duplicate claim. Medicare has already processed this service on another claim. Please check the
status of all other claims on file for this date of service.
The Medicare # or name was Missing, Incomplete, or Invalid.
The provider was not certified or eligible to be paid for this procedure on this date of service.
The provider was not certified or eligible to be paid for this procedure on this date of service.
The Procedure Code was Missing, Incomplete, or Invalid.
The Medicare number was Missing, Incomplete, or Invalid.
The Referring Provider NPI was Missing, Incomplete, or Invalid.
Medicare will only pay for a screening mammogram once every 12 months unless high risk factors are
present.
Benefit maximum for this time period has been reached.
This item or service was denied because information required to make payment was incorrect. The FDA
approval number was missing, incomplete or invalid.
This service is not paid separately when the patient is an inpatient.
This service was denied because Medicare only covers this service once in the Beneficiary's lifetime.
The name or Medicare number was incorrect or missing.
The Procedure Code was Missing, Incomplete, or Invalid.
The beneficiary overpaid for these services. You must issue a refund to the beneficiary within 30 days.

309
310
313
317
318

319

This procedure requires that a qualifying service be received and covered. The qualifying procedure has not
been received. Please refer to your CPT manual to determine the appropriate qualifying procedure for this
add on code.
This provider was not certified or eligible to perform this procedure on this date of service.
The diagnosis is inconsistent with the patient's gender.
This procedure falls under Correct Coding Initiative guidelines. Payment is included in the allowance for
another procedure or service. Please check your Correct Coding Combinations.
This allowance has been reduced by the amount previously paid for a related procedure.
This procedure requires that a qualifying service be received and covered. The qualifying procedure has not
been received. Please refer to your CPT manual to determine the appropriate qualifying procedure for this
add on code.
The allowed amount has been reduced because a component of the basic procedure or test was paid.

320

323
329
333
337
339
341
342
343
347
348
352
353

358
359
361
362
368
370
371
373
376
377

This procedure requires that a qualifying service be received and covered. The qualifying procedure has not
been received. Please refer to your CPT manual to determine the appropriate qualifying procedure for this
add on code.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.
The service was not approved by the Food and Drug Administration.
This is a duplicate claim. Medicare has already processed this service on another claim. Please check the
status of all other claims on file for this date of service.
Monthly rental payments can continue until the earlier of the 15th month from the first rental month, or the
month when the equipment is no longer needed.
Payment is adjusted when performed by provider of this specialty.
This is a duplicate of a charge already submitted by another provider.
The claim did not show if the test was purchased by the physician or if the physician performed the test.
Claim or service denied because information requested was not received.
No payment can be made because the item has reached the 15 month limit. Separate payments can be made
for maintenance or servicing every 6 months.
This is a non-covered service because it is not deemed medically necessary.
This is a Railroad Medicare Beneficiary Please submit your claim to the Railroad Retirement Board Contractor.
This procedure requires that a qualifying service be received and covered. The qualifying procedure has not
been received. Please refer to your CPT manual to determine the appropriate qualifying procedure for this
add on code.
This is a non-covered service by Medicare.
This is the 10th rental month in period; supplier should offer the option to purchase item.
The procedure code submitted was adjusted because the documentation submitted does not support the
level of service billed.
Payment adjusted because the modifier reported was invalid on the date of service.
The claim was separated to expedite processing. You will receive a separate notice for the other services
billed.
The information provided does not support the need for this service or item.
This item or service was denied because information required to make payment was incorrect.
Claim or service denied because information requested was not received.
Payment for transportation is allowed only to the closest facility that can provide the necessary care.

378
380
381
382
383
384
385
387
392
393

394
401
402
403
405
406
407
408
409
411
413
414
415
417
420

421

422
423
425
426

Claim or service denied because information requested was not received.

The information provided does not support the need for this service or item.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.
Procedure or treatment has not been deemed 'proven to be effective' by the payer.
The procedure code submitted was adjusted because the information submitted does not support the level of
service billed.
This is a duplicate of a charge already submitted by another provider.
Your billed amount is more than Medicare's fee schedule allowed amount. Reimbursement is based on the
Fee Schedule.
Payment adjusted because the payer deems the information submitted does not support this many services.
This payment was sent to the beneficiary or their responsible party.
Medicare is the secondary payer. Check the patients eligibility and submit claim to primary insurance.
This procedure requires that a qualifying service be received and covered. The qualifying procedure has not
been received. Please refer to your CPT manual to determine the appropriate qualifying procedure for this
add on code.
This is a non-covered service by Medicare.
This item is not covered because the prescription is incomplete.
Service is not covered because the patient is enrolled in a Hospice.
This is a duplicate claim. Medicare has already processed this service on another claim. Please check the
status of all other claims on file for this date of service.
The service is not covered by this contractor. The facility should bill this service to the Medicare Part A
Contractor.
This item or service is not covered when performed, referred or ordered by a provider of this specialty.
This is a duplicate claim. Medicare has already processed this service on another claim. Please check the
status of all other claims on file for this date of service.
This is a non-covered service by Medicare.
Medicare does not pay for multiple physicians or assistants in this case.
The information provided does not support the need for this item or service.
The information provided does not support the need for this service or item. There were no X-rays taken
within the past 12 months or near enough to the start of treatment.
Claim denied because the equipment is the same or similar to equipment already in use.
The information provided does not support the need for this item or service.
A specimen collection fee was not billed. Therefore, a travel allowance was not paid.
Services were denied because this claim was sent to the incorrect contracter. This claim will need to be
submitted to the durable medical equipment medicare administrative contractor or Medicaid agency.
This procedure requires that a qualifying service be received and covered. The qualifying procedure has not
been received. Please refer to your CPT manual to determine the appropriate qualifying procedure for this
add on code.
This service was denied because information required to make payment was incorrect.
This beneficiary was not covered by Medicare Part B on this date of service.
This is a non-covered service because it is not deemed medically necessary.

429

The benefit for this service is included in the payment or allowance for another service or procedure that has
already been processed on this date of service. Please check the status of all other claims on file for this date
of service.

435
437
438
439
440

Services are denied when performed by a Provider to an immediate relative or member of their household.
The provider was not certified or eligible to be paid for this procedure on this date of service.
This procedure requires that a qualifying service be received and covered. The qualifying procedure has not
been received. Please refer to your CPT manual to determine the appropriate qualifying procedure for this
add on code.
This is a non-covered service by Medicare.
The time limit for filing has expired. You may not appeal this decision.
This service denied based on the diagnosis code reported.
The provider was not certified or eligible to be paid for this procedure on this date of service.

441
442

This item or service is not covered when performed, referred or ordered by a provider of this specialty.
Payment was adjusted or reduced because multiple procedures were done on the same day.

443
444

Payment for charges adjusted. Charges are covered under a capitation agreement or managed care plan.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.

445
446
447

Services are denied when performed by a Provider to an immediate relative or member of their household.
These are non-covered charges. This immunization and/or preventive care is not covered by Medicare.
This is a duplicate of a charge already submitted by another provider.

448
450
452

This item or service is not covered when performed, referred or ordered by a provider of this specialty.
These are non-covered charges. Cosmetic surgery and related services are not covered.
Payment will be denied when the service is provided outside of the United States.

456
458
459
460

Charges denied/reduced because procedure/service was partially or fully furnished by another provider.
The name, strength, or dosage of the drug used was missing, incomplete or invalid
The diagnosis code billed is inconsistant with the procedure code.
The date this claims was billed was prior to the date of the service.

461

Charges denied/reduced because procedure/service was partially or fully furnished by another provider.
This patient has been seen by the same provider or a provider within your group within the past three years,
therefore a new patient procedure code cannot be billed.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.
Our records show that the date of death is before the date of service.
Medicare does not pay for acupuncture
Payment is adjusted when performed or ordered by a provider of this specialty.
The benefit for this service is included in the payment or allowance for another service or procedure that has
already been processed on this date of service.
This payment was sent to the beneficiary or their responsible party.
The service is not covered by this contractor. The facility should bill this service to the Medicare Part A
Contractor.

432
433

463
464
465
466
467
468
470
471

472
478
480
483
486
487
490
493
494
495
496
498
499
502
510
522
527
531
533
552
553
556
558
566
573
574
585
587
588
595
597
601

The services were applied to the beneficiary's blood deductible. The first three pints of blood used in each
year are not covered.
This is a non-covered service by Medicare.
Payment is adjusted when performed by provider of this specialty.
The information provided does not support the need for this service or item.
This is a non-covered service by Medicare.
This is a non-covered service because it is either a routine exam or a screening procedure done in conjunction
with a routine exam.
This is an informational message. The claim was submitted as unassigned but processed as an assigned claim
because the provider agreed to accept assignment for all claims.
Payment adjusted because the payer deems the information submitted does not support this many services.
This is a non covered service. Eye refractions are considered routine services and are not covered by
Medicare.
Non-covered charges. Routine care is not covered by Medicare.
Payment adjusted because the payer deems the information submitted does not support this many services.
This is a payment message. Medicare has paid interest to the payment because processing time limits were
exceeded.
This is a non-covered service by Medicare.
This is not a denial. Medicare approved less for this individual test because it can be done as part of a
complete panel of tests.
These are non-covered charges. Eyeglasses or contact lenses are only covered after cataract surgery or if the
natural lens of your eye is missing.
This payment was sent to the beneficiary or their responsible party.
This service is not covered when billed this type of provider.
Payment adjusted because the payer deems the information submitted does not support this many services.
The submitted documentation do not match the claim. Therefore, the service is non-covered because it is
not deemed medically necessary.
Payment adjusted because coverage and/or program guidelines were not met or were exceeded.
This payment was sent to the beneficiary or their responsible party.
Services not documented in patient's medical records
The plan of treatment was missing, incomplete, or invalid.
The claim lacks information which is needed for processing.
The payment for this service is included in the allowance for another service or procedure.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.
This payment was sent to the beneficiary or their responsible party.
This service is not covered when billed by an independent therapist.
This is a duplicate of a charge already submitted by another provider. This service is not paid separately when
the beneficiary is an inpatient.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.
The maximum benefits for the year have been reached for this patient.
The Billing and/or Referring Provider NPI was missing, invalid, or incomplete.

602
603
605
606
610
611
613

614
615
617
624
631
633
634
635
637
641
643
645
647
649
653
655
657
658
670
671
672
673
674
678
681
682
683

This patient is a member of an employer-sponsored prepaid health plan. Services from outside that health
plan are not covered.
Only one hospital visit or consultation per provider is allowed per day.
The information submitted does not support this many services withing this time period.
This service is not covered when billed this type of provider.
Payment adjusted because the payer deems the information submitted does not support this many services.
These are non-covered charges.
A screening mammogram is covered only once for women under age 40.
Payment adjusted because the payer deems the information submitted does not support this many services.
Medicare will only pay for a screening mammogram once every 12 months unless high risk factors are
present.
This service is being denied because it has not been 12 months since the last time the patient had this service
Payment is denied when performed or billed by this type of provider in this type type of facility. This facility is
not certified for digital mammography.
The place of service is missing, incomplete, or invalid.
These are non-covered charges. Routine care is not covered by Medicare.
This service was denied because information required to make payment was incorrect.
This service was denied because information required to make payment was incorrect.
The claim lacks information which is needed for processing.
The patient's health identification number and name do not match.
Medicare does not pay for multiple physicians or assistants in this case.
The claim lacks information which is needed for processing.
The provider was not certified or eligible to be paid for this procedure on this date of service.
This is an add-on procedure code and the primary procedure was not billed or was not billed on the same
claim for the same date of service.
The information provided does not support the need for this service.
This is a duplicate of a charge already submitted by another provider.
This is a duplicate claim. Medicare has already processed this service on another claim. Please check the
status of all other claims on file for this date of service.
This allowance has been reduced by the amount previously paid for a related procedure.
The information provided does not support the need for this service or item.
Service is being denied because it has not been 12 months since the beneficiary's last test or procedure of this
kind.
Service is being denied because it has not been 24 months since the beneficiary's last test or procedure of this
kind.
This service is being denied because it has not been 4 years since the last time the patient had this service
This service is not covered unless the beneficiary is classified as a high risk for colorectal cancer.
This is a duplicate claim. Medicare has already processed this service on another claim. Please check the
status of all other claims on file for this date of service.
The beneficiary has elected to receive religious nonmedical healthcare.
This is considered a noncovered service because a Pancreas transplant is not covered unless a kidney
transplant is performed.
The CLIA certification number was Missing, Incomplete or Invalid.
The CLIA certification number was Missing, Incomplete or Invalid.

684
685
686
687
691
695
698
701
707
708
709
712
718

720
721
722
725
726
730
754
755
758
759
760
761
762
764

766

Claim lacks information which is needed for processing. Please resubmit the claim with a break-down of the
charges.
This claim or service lacks information which is needed for it to be processed. This claim was adjusted
because there was an error in billing.
The claim lacks information which is needed for processing.
The service was partially or fully furnished by another provider. The test must be billed by the laboratory that
did the work.
This is an add-on procedure code and the primary procedure was not billed or was not billed on the same
claim for the same date of service.
Payment adjusted because coverage and/or program guidelines were not met or were exceeded.
Payment is included in another service received on the same day.
Medicare does not routinely issue checks of less than $1.00. The amount due will be included in your next
check.
The laboratory was not certified or eligible to be paid for this procedure on this date of service.
The provider was not certified or eligible to be paid for this procedure on this date of service.
The laboratory was not certified or eligible to be paid for this procedure on this date of service.
The laboratory was not certified or eligible to be paid for this procedure on this date of service.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.
Our records show that an automobile, medical, liability, or no-fault insurance plan is primary for these
services. Submit this claim to the primary insurance. When submitting this claim to Medicare, include the
primary payor information.
This service is not paid separately when the Beneficiary is an inpatient. Payment is included in the
reimbursement issued to the facility.
This service is not paid separately when the Beneficiary is an inpatient. Payment is included in the
reimbursement issued to the facility.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.
This is an informational payment message. Medicare paid as secondary for this service.
This is not a denial. Payment is made conditionally and may be retracted if the beneficiary is enrolled in a
Home Health Episode.
The benefit for this service is included in the payment or allowance for another service or procedure that has
already been processed on this date of service.
This procedure falls under Correct Coding Initiative guidelines. Payment is included in the allowance for
another procedure or service. Please check your Correct Coding Combinations.
This service cannot be paid when provided in this location or facility.
This service cannot be paid when provided in this location or facility.
These are non-covered charges.
This are non-covered charges.
The benefit for this service is included in the payment or allowance for another service or procedure that has
already been processed on this date of service.
This service has been denied by Medicare because the beneficiary may have funds set aside from a Worker's
Compensation Settlement to pay for future medical expenses and prescription drug treatment related to an
injury. Please verify this information with the patient.

838
839

This adjustment is based on a Recovery Audit. For questions regarding the adjustment please contact the
Recovery Audit Contractor at 1-866-201-0580.
This adjustment is based on a Recovery Audit. For questions regarding the adjustment please contact the
Recovery Audit Contractor at 1-866-201-0580.
This service is denied when billed by a provider of this type or specialty.
This Claim was not billed being in accordance with ambulatory surgical center guidelines.
Separately billed services or tests have been bundled as they are considered components of the same
procedure. Separate payment is not allowed.
Payment is denied when performed or billed by this type of provider in this type type of facility. Payment is
included in the reimbursement issued to the facility.
This service denied because the hospital stay or surgery is not on file for the implantation of the Durable
Medical Equipment or prosthetic device.
This service is not covered when billed this type of provider when the beneficiary is in a Medicare Part A
covered Skilled Nursing Facility.
This is a duplicate claim. Medicare has already processed this service on another claim. Please check the
status of all other claims on file for this date of service.
The benefit for this service is included in the payment or allowance for another service or procedure that has
already been processed on this date of service.
This service is not covered when billed this type of provider.
The provider was not certified or eligible to be paid for this procedure on this date of service.
Medicare does not pay for multiple physicians or assistants in this case.
A screening mammogram is covered only once for women under age 40.
This service is not paid separately when the Beneficiary is an inpatient. Payment is included in the
reimbursement issued to the facility.
The service is not covered by this contractor. The facility should bill this service to the Medicare Part A
Contractor.
Payment adjusted because the information does not support this level of service.
The patient has Railroad Retirement benefits. Please send the claim to the Railraod Retirement Board
Medicare Carrier.
This beneficiary was not covered by Medicare Part B on this date of service.
This is an informational payment message. This service was reduced due to the psychiatric reduction.
Full payment was not made because the yearly limit has been met.
Only one hospital visit or consultation per provider is allowed per day.
Only one hospital visit or consultation per provider is allowed per day.
Payment is included in another service received on the same day.
For this date of service the beneficiary was covered under a Medicare Advantage Plan. This plan replaces feefor-service medicare. Please send claim to the Medicare Advantage Plan.
Payment adjusted because coverage and/or program guidelines were not met or were exceeded.
This is an informational message. The claim was separated for processing. The remaining services may
appear on a separate notice.
This is an informational message. The claim was separated for processing. The remaining services may
appear on a separate notice.
The cost of care before and after the surgery is included in the approved amount for the service.

841
842
843

Payment is denied because the prescription is not current.

This service is not covered when billed this type of provider.
This service is not covered when billed this type of provider.

767
768
785
787
788
789
793
794
796
797
801
802
803
806
807
808
810
811
816
818
819
825
829
831
834
836
837

846
856
859
860
862
864
865
868
870
871
875

878
879
881
883
886
891
894
896
900
902
906
908
910
911
914
915
916
917

The time limit for filing has expired. You may not appeal this decision.
This payment was sent to the beneficiary or their responsible party.
This beneficairy has Federal Black Lung benefits.
The Patients name and Medicare number do not match
The claim denied because this is a work-related injury or illness and therefore the liability of the Worker's
Compensation Carrier.
The name or Medicare number was incorrect or missing.
Payment is included in another service received on the same day.
This payment was sent to the beneficiary or their responsible party.
Our records show that you have opted out of Medicare. The patient is responsible for payment.
Our records show that you have opted out of Medicare. The patient is responsible for payment.
These are noncovered services because this is not deemed medically necessary.
This procedure requires that a qualifying service be received and covered. The qualifying procedure has not
been received. Please refer to your CPT manual to determine the appropriate qualifying procedure for this
add on code.
The claim or service lacks information which is needed for processing. The place of service is missing,
incomplete or invalid.
This payment was sent to the beneficiary or their responsible party.
This claim or service lacks information which is needed for it to be processed. The information we requested
was not received.
These are non covered charges. Medicare does not cover an ambulance service to a funeral home.
The procedure code submitted was adjusted because the documentation submitted does not support the
level of service billed.
These services or items are not approved by the Food and Drug Administration and therefore, are not
covered.
This service is not payable within our claims jurisdiction area. You can identify the correct Medicare contractor
to process this service by accessing the CMS website at www.cms.gov.
This is a payment message. This surgery was reduced because it was performed with another surgery on the
same day.
These are noncovered services because this is not deemed medically necessary.
This is a non covered service. Eye refractions are considered routine services and are not covered by
Medicare.
The name or Medicare number was incorrect or missing.
The claim lacks information which is needed for processing.
The procedure code and modifier were invalid for the date of service
This payment was sent to the beneficiary or their responsible party.
This is a duplicate claim. Medicare has already processed this service on another claim. Please check the
status of all other claims on file for this date of service.
This service is not payable within our claims jurisdiction area. You can identify the correct Medicare contractor
to process this service by accessing the CMS website at www.cms.gov.
Lifetime Benefit Maximum has been reached. This service is covered up to 12 months after transplant and
release from the hospital.
The allowed amount has been reduced because a component of the basic procedure or test was paid.

918
919
921

The claim was denied because the payer deems the information submitted does not support this many
services. This service is only covered once every 24 months unless high risk factors are present.
Treatment was rendered in an inappropriate or invalid place of service.

929

Medicare Part B does not cover this service because the patient was enrolled in Hospice for this date of
service.
Medicare does not pay for an assistant surgeon for this procedure/surgery.
This procedure code cannot be billed in place of service.
Information required to make payment was missing.
This care may be covered by another payer per coordination of benefits.
Our records show that an automobile medical, liability, or no-fault insurance plan is primary for these services.
Submit this claim to the primary insurance.

930

Medicare is secondary for the beneficiary for this date of service. Please send the claim to the primary payer.

931
932

Medicare is secondary for the beneficiary for this date of service. Please send the claim to the primary payer.
This is a payment message. Allowed amount was adjusted or reduced because multiple procedures were
done on the same day.

933
934
935
936
937

The patient is covered by the Black Lung Program. Please send the claim to the Federal Black Lung Program.
This payment was sent to the beneficiary or their responsible party.
This payment was sent to the beneficiary or their responsible party.
These are non covered services because this is not deemed medically necessary.
Payment was adjusted because of the amount paid by the primary insurer.

939

Medicare is secondary for the beneficiary for this date of service. Please send the claim to the primary payer.

940
941

Medicare is secondary for the beneficiary for this date of service. Please send the claim to the primary payer.
This claim is denied because the services may be related to a worker's compensation injury or illness. Please
submit the claim to the worker's compensation carrier.

942
943
944
946
947
948
949

Medicare is secondary for the beneficiary for this date of service. Please send the claim to the primary payer.
This service is not covered when billed this type of provider.
Claim denied because this care may be covered by another payer per coordination of benefits.
Claim denied because this care may be covered by another payer per coordination of benefits.
Claim denied because this care may be covered by another payer per coordination of benefits.
This claim denied because this injury or illness is the liability of the no-fault carrier.
Claim denied because this care may be covered by another payer per coordination of benefits.

950
951
954
955
958
959
960
964

Claim denied reduced because charges have been paid by another payer as part of coordination of benefits.
Payment was adjusted because the patient's primary insurance satisfied the bill.
This item or service cannot be paid unless the provider accepts assignment.
This is a noncovered service unless the provider accepts assignment on the claim.
The provider was not certified or eligible to be paid for this procedure on this date of service.
The provider was not certified or eligible to be paid for this procedure on this date of service.
The procedure code and modifier were invalid for the date of service
The provider was not certified or eligible to be paid for this procedure on this date of service.
These are non-covered services because this is not deemed a 'medical necessity' by the payer. The
information provided does not support the need for this service or item.
This service was denied because information required to make a payment was incorrect.

922
924
925
926
927

966
967

973

The claim is lacking information that is required for processing

The patient is liable for the charges for this service as you informed the patient in writing before the service
was furnished that Medicare would not pay for it.

976
978
979

Medicare is secondary for the beneficiary for this date of service. Please send the claim to the primary payer.
The procedure code is inconsistent with the patient's age.
The procedure code and modifier were invalid for the date of service

980

996
997
A01
A02

The claim did not show if the test was purchased by the physician or if the physician performed the test.
The purchase price for the test and or the performing laboratory's name and address were missing,
incomplete or invalid
The service is non-covered because it is not deemed medically necessary
Payment was adjusted because the patient's primary insurance satisfied the bill.
The procedure code is inconsistent with the patient's age. Service is not covered when beneficiary is under
age 50.
Service is being denied because it has not been 12 months since the beneficiary's last test or procedure of this
kind.
Service is being denied because it has not been 12 months since the beneficiary's last test or procedure of this
kind.
The Diagnosis Code was missing, incomplete, or invalid.
The information provided does not support the need for this service or item.
The information provided does not support the need for this service or item.

A03

Payment adjusted because the payer deems the information submitted does not support this many services.

A04
A05
A06

Payment adjusted because the payer deems the information submitted does not support this many services.
Procedure or treatment has not been deemed 'proven to be effective' by the payer.
Procedure or treatment has not been deemed 'proven to be effective' by the payer.
The procedure code submitted was adjusted because the information submitted does not support the level of
service billed.
This claim was chosed for complex review and was denied after reviewing medical records because it was not
deemed medically necessary.
This claim was chosen for complex review and was denied after reviewing medical records because it was not
deemed medically necessary.
This claim was chosen for complex review and was denied after reviewing medical records because the
records do not support this many services.
After reviewing the medical documentation, it was determined the information provided does not support
this many services.
This claim was chosen for complex review and was denied after reviewing medical records because it was not
deemed 'proven to be effective' by the payer.
This claim was chosen for complex review and was denied after reviewing medical records because it was not
deemed 'proven to be effective.'
This claim was chosed for complex review and was denied after reviewing medical records because it was not
deemed medically necessary.
Biofeedback therapy is not covered in a home place of service.

969

985
991
992
994
995

A08
A10
A11
A12
A13
A14
A15
A16
A18
A20

Medicare does not pay for this item or service.

A24
A25
A28
A29
A31
A34
A42
A43
A44
A45
A48
A51
A52
A53
A55
A56
A57
A58
A59
A60
A61
A63
A64
A66
A67
A68
A73
A74
A75
A78
A80
A81
A84
A85
A88

Medicare does not pay for this item or service.

Payment adjusted because coverage and/or program guidelines were not met or were exceeded.
This procedure or product is not approved by the Food and Drug Administration.
Payment for this service is made under Medicare Part A. Please submit the bill to Part A.
This is a duplicate claim. Medicare has already processed this service on another claim. Please check the
status of all other claims on file for this date of service.
This is a duplicate of a charge already submitted by another provider.
Our records show that you have opted out of Medicare. The patient is responsible for payment.
The diagnosis codes billed are not covered. Please verify the diagnosis requirements for the procedure code
billed.
The diagnosis codes billed are not covered. Please verify the diagnosis requirements for the procedure code billed.
Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
The diagnosis is not covered.
Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
This service is not covered when billed this type of provider. The ambulatory surgical center must bill for this
service.
The Beneficiary's coverage was terminated prior to the date of service.
The procedure code and modifer combination is invalid or a required modifier is missing.
These are non-covered charges. Claims for these drugs must be billed by the appropriate drug vendor rather
than the rendering provider.
These are non covered services because this is not deemed a medical necessity by the payer.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount.
Payment was adjusted as this item or service is not covered when performed or ordered by a provider of this
specialty.
These are non-covered charges.
These are non-covered charges.
These are non-covered charges.
The diagnosis code billed is inconsistant with the patient's age.
Payment was adjusted as this item or service is not covered when performed or ordered by a provider of this
specialty.
Payment adjusted because the payer deems the information submitted does not support this many services.
These are non-covered charges. Medicare cannot pay for the administration of the drug being billed because
these drugs are not available from the Competative Acquisition Program vendor.
The Billing Provider NPI was missing, incomplete, or invalid.
The referring providers information was missing, incomplete, or invalid.
The supervising providers information was missing, incomplete, or invalid.
The Rendering Provider informaion was missing, incomplete, or invalid.
Service is being denied because it has not been 12 months since the beneficiary's last test or procedure of this
kind.
Payment adjusted because the payer deems the information submitted does not support this many services.
The number of days or units of service exceeds our acceptable maximum.
Payment adjusted because coverage and/or program guidelines were not met or were exceeded.
This service is not deemed to be medically necessary.
The Billed Amount was missing, incomplete, or invalid.

A89

A90
A91

Medicare does not pay for this item or service.

The information provided does not support the need for this service or item. You may bill the beneficiary for
these services as they have signed an Advanced Beneficiary Notice.

B32

This service was denied because Medicare only covers this service once in the Beneficiary's lifetime.
This claim or service lacks information which is needed for processing. The primary payer information was
either missing or incomplete.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.
The benefit for this service is included in the payment or allowance for another service or procedure that has
already been processed on this date of service.
This service is not covered. Medicare does not pay for missed appointments.
The place of service was either missing, incomplete or invalid.
This is a payment message. Allowed amount was adjusted or reduced because multiple procedures were
done on the same day.
The procedure code is inconsistent with the modifier used or a required modifier is missing.
This Procedure is not covered when billed in this place of service.
This service is not covered when billed by a provider this type of Provider.
These are non-covered charges. This procedure denied against a National Coverage Determination (NCD)
Policy for not meeting medical necessity requirements.
This service was denied because Medicare only covers this service once in the Beneficiary's lifetime. This
service must be done within 12 months of the beneficiary's entitlement date.
This service is paid only once in a patient's lifetime.
This procedure requires a referring provider.
These are non-covered charges.
This claim/service was chosen for complex review and was denied after reviewing the medical records. The
supporting documentation lacks a valid provider signature.
Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service
according to a Local Coverage Determination.
Payment was adjusted because the coverage or program guidelines were not met or were exceeded
These are non-covered charges. This immunization and/or preventive care is not covered by Medicare.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Your referring or ordering provider information may also be invalid. Please verify this information
with the referring provider.
The diagnosis codes billed are not covered. Please verify the diagnosis requirements for the procedure code
billed.
These are non-covered charges. Services were denied because the beneficiary was not in United States
territory or within territorial waters.
This procedure requires that a qualifying service be received and covered. The qualifying procedure has not
been received. Please refer to your CPT manual to determine the appropriate qualifying procedure for this
add on code.

B36

Service is being denied because it has not been 12 months since the beneficiary's last procedure of this kind.

B37

Service is being denied because it has not been 12 months since the beneficiary's last procedure of this kind.
This is a duplicate claim. Medicare has already processed this service on another claim. Please check the
status of all other claims on file for this date of service.

A92
A93
A95
A96
A97
A99
B01
B08
B09
B12
B14
B15
B16
B17
B19
B22
B25
B27

B28
B29
B30

B38

B39
B40
B41
B42
B47

B48
B56
B58
B62
B76
B80
B82
B88
B89
B91
B98
B99
C02
C03
C06
C07
C11
C12
C13
C14
C15
C17
C19
C30
C32
C33

The benefit maximum for this time period has been reached.
The benefit maximum for this time period has been reached.
The diagnosis codes billed are not covered. Please verify the diagnosis requirements for the procedure code billed.
The diagnosis codes billed are not covered. Please verify the diagnosis requirements for the procedure code
billed.
This is a duplicate claim. Medicare has already processed this service on another claim. Please check the
status of all other claims on file for this date of service.
Medicare will not pay for a Medical Nutrition Therapy service and a Diabetes Self Management Training
performed on the same day
The provider was not certified or eligible to be paid for this procedure on this date of service.
The provider was not certified or eligible to be paid for this procedure on this date of service.
This service was denied due to Incomplete or invalid medical documentation which could include orders,
notes, reports, or charts.
The new patient qualifications were not met.
The procedure code was missing, incomplete, or invalid.
This service is not covered when performed with a non-covered service.
The benefit for this service is included in the payment or allowance for another service or procedure that has
already been processed on this date of service.
The days or units of service were missing, incomplete, or invalid. The information submitted does not support
this many services.
This service is non covered because the procedure code billed was invalid or incorrect for this date of service.
This is an informational payment message. Your billed amount is more than Medicare's fee schedule allowed
amount. Reimbursement is based on the Fee Schedule.
The procedure code is inconsistent with the modifier used or a required modifier is missing. The professional
component of the service must be billed separately.
This claim was chosed for complex review and was denied after reviewing medical records because it was not
was not deemed medically necessary.
This claim was chosen for complex review and was denied after reviewing medical records because it was not
was not deemed medically necessary.
This adjustment is based on a Recovery Audit. For questions regarding the adjustment please contact the
Recovery Audit Contractor at 1-866-201-0580.
This service was deemed not medically necessary because the other diagnosis was missing, incomplete, or
invalid.
This diagnosis is not covered by Medicare.
This diagnosis is not covered by Medicare.
The benefit maximum for this time period has been reached.
The benefit maximum for this time period has been reached.
Treatment was rendered in an inappropriate or invalid place of service.
The number of days or units of service exceed the benefit acceptable maximum.
The number of services exceeds the frequency allowed within the time period without supporting
documentation.
This service is not deemed a medically necessary.
This service was deemed not medically necessary,
Either the diagnosis is not covered or the other diagnosis is missing, incomplete, or invalid.

C35
C37
C39
C40
C42
C43
C44

C45
C50
C51

This service is not covered by this contractor. A facility is responsible for payment to outside providers who
furnish these services to its patients.
The provider was not certified or eligible to be paid for this procedure on this date of service.
The benefit for this service is included in the payment or allowance for another service that has already been
processed on this date of service.
This procedure is inconsistent with the modifier billed on the claim or the appropriate modifier is missing.
The Lifetime Benefit Maximum was met for this benefit or service. This service is paid once in a patient's
lifetime.
Medicare only covers one Annual Wellness Visit within a 12 month period.
This service occurred too soon after the patients initial Preventive Physical Exam.
The annual wellness visit is only payable for an individual who is no longer within 12 months after the
effective date of their first Medicare coverage and have not received either an initial preventive physical exam
or an annual wellness visit within the past 12 months.
This is a non-covered service because it is not deemed medically necessary.
Medicare does not pay for this service because it is statutorily excluded.