Denial code N115 occurs when a service or item is not deemed medically necessary based on a Local Coverage Determination (LCD) or Local Medical Review Policy (LMRP). These denials can lead to lost reimbursements, delayed payments, and administrative burdens for healthcare providers, billing teams, and practice managers.
By understanding why N115 denials happen and implementing proactive solutions, you can reduce claim rejections and optimize revenue cycles.
Common Reasons for N115 Denials
- LCD Frequency Limits – The service exceeds the number of times allowed within a set timeframe.
- Overlap or Overutilization Issues – Billing the same service too frequently based on LCD policy triggers a denial.
- Outdated Prescription or Policy Changes – The item or service is no longer covered due to updated LCD guidelines.
- Missing Diagnosis or Modifier Codes – Some services require specific diagnosis or modifier codes for reimbursement.
- Lack of Supporting Documentation – Insufficient records to justify medical necessity based on LCD definitions.
How to Prevent N115 Denials
To reduce N115 denials and improve claim approvals, follow these best practices:
- Match LCD Criteria Before Billing – Check that the service or procedure meets the latest LCD requirements.
- Ensure Complete Medical Documentation – Provide detailed physician notes, diagnostic reports, and clinical justification.
- Use Correct Diagnosis & Modifier Codes – Apply LCD-approved diagnosis codes and necessary modifiers to support claims.
- Verify Coverage & Obtain Advance Beneficiary Notice (ABN) – If the service is unlikely to be covered, get an ABN signed to inform the patient.
- Stay Updated on LCD Changes – Regularly review LCD updates on CMS.gov and confirm payer-specific requirements.
- Appeal Denials with Strong Justification – If denied, submit an appeal with detailed documentation demonstrating medical necessity.
- Train Billing Staff on LCD Compliance – Educate teams on LCD policies, required documentation, and common denial trends.
Eliminate N115 Denials with Claims Med
Dealing with N115 denials can be complex, but Claims Med simplifies the process. Our expert billing solutions, denial management, and revenue cycle optimization services help healthcare providers reduce denials, maximize reimbursements, and streamline claim processing.
Don’t let medical necessity denials hurt your revenue! Contact Claims Med today to learn how our customized solutions can improve your bottom line.