Decision based on a Local Coverage Determination
Medicare applied a Local Coverage Determination (LCD) policy; the service, diagnosis or frequency did not meet it.
Usual causes
- Diagnosis not in the LCD's covered list.
- Frequency or documentation requirements in the LCD not met.
- Covered diagnosis documented but not on the claim.
The fix
Read the LCD named in the remittance (Medicare Coverage Database). If a documented, covered diagnosis was left off, send a corrected claim. Otherwise appeal with records that show the patient meets the LCD criteria. If an ABN was signed, bill the patient with GA.
Appeal or corrected claim?
Appeal with records; corrected claim only for incomplete coding.
Deadline to watch
Medicare redetermination: 120 days from the remittance date.
Exact limits are in your payer contract or provider manual. When in doubt, send the correction or appeal this week.
Often seen together
Medicare applied a Local Coverage Determination and the diagnosis or frequency did not meet it. Appeal with records, or bill the patient with GA if an ABN was signed.
N115 in short
What does N115 mean?
Medicare applied a Local Coverage Determination (LCD) policy; the service, diagnosis or frequency did not meet it. The official X12 text reads: "This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LCD."
What usually causes a N115 denial?
Diagnosis not in the LCD's covered list. Frequency or documentation requirements in the LCD not met. Covered diagnosis documented but not on the claim.
How do I fix N115?
Read the LCD named in the remittance (Medicare Coverage Database). If a documented, covered diagnosis was left off, send a corrected claim. Otherwise appeal with records that show the patient meets the LCD criteria. If an ABN was signed, bill the patient with GA.
Should I appeal N115 or send a corrected claim?
Appeal. Appeal with records; corrected claim only for incomplete coding.
What deadline applies to N115?
Medicare redetermination: 120 days from the remittance date.