Medical Necessity

Common Causes for 50

Denials with code 50 typically happen for the following specific reasons:

• Service billed does not meet payer’s Local Coverage Determination (LCD) or National Coverage Determination (NCD) criteria for medical necessity.
• Insufficient or missing documentation in the medical record to support the medical necessity of the service (e.g., lack of diagnosis, clinical rationale, or progress notes).
• Use of diagnosis codes that indicate routine, preventive, or screening services rather than active treatment of a diagnosed condition.
• Service is considered experimental, investigational, or cosmetic and not covered under the patient’s benefit plan.
• Incorrect or missing modifiers that are required to indicate medical necessity or justify the service under payer guidelines.

How to Prevent 50 Denials

To avoid receiving this denial in the future, implement these specific checks:

• Verify that the service is covered under the payer’s LCD/NCD and that the diagnosis code supports medical necessity.
• Ensure all required documentation (clinical notes, diagnosis, treatment plan, and rationale) is complete and legible before claim submission.
• Use appropriate modifiers (e.g., GA for Advance Beneficiary Notice) when billing for services that may not meet medical necessity but are provided after patient notification.
• Conduct pre-claim audits to confirm coding accuracy and alignment with payer medical necessity requirements.
• Educate clinical staff on payer-specific documentation requirements for medical necessity and regularly update them on policy changes.

Appeal Letter Template for 50

If you believe this claim was denied incorrectly, you can use the following template to submit an appeal.

[Your Practice Header]
[Date]

[Payer Name]
[Appeals Department Address]

RE: Appeal for Claim [Claim Number]
Patient: [Patient Name]
ID: [Patient ID]
Date of Service: [Date]
Denial Code: 50 - Medical Necessity

Dear Appeals Department,

I am writing to appeal the denial of the above-referenced claim, which was denied with code 50: "Medical Necessity".

The service in question was provided as part of a medically necessary treatment plan for the patient’s diagnosed condition, as documented in the clinical record. The documentation includes a clear diagnosis, clinical rationale, and evidence of the patient’s response to treatment, all of which support the medical necessity of the service. The service aligns with accepted medical standards and payer guidelines, and there is no evidence to suggest it was experimental, investigational, or cosmetic. Therefore, the denial based on medical necessity is not supported by the clinical facts and should be reconsidered for payment.

Attached please find:
1. A copy of the original claim.
2. The relevant medical records supporting the service.
3. [Any other supporting documents].

We respectfully request that you reprocess this claim for payment.

Sincerely,

[Your Name]
[Title]
[Practice Name]