Clinical documentation tip: Reduce concomitant narcolepsy medication denials

The AASM Payer Policy Review Committee (PPRC) has received several member inquiries regarding denials for prescribing concomitant medications for the treatment of narcolepsy. Following review of several payers’ pharmaceutical policies and a meeting with a payer representative, it is clear that payers have a general lack of understanding regarding the necessity of multiple medications for the treatment of narcolepsy.

To ensure that the medical necessity is clear, the PPRC recommends that prescribers document the following details in the medical record:

1. Efficacy of the originally prescribed medication and length of time taken by the patient
2. Necessity for the patient to continue the original medication
3. Reason for adding an additional medication to the patient’s current regimen for narcolepsy treatment

If the provision of this more detailed documentation fails to reduce denials, then we suggest you follow the appeals process and request a peer-to-peer review, if necessary.

Members may send coding and reimbursement questions to coding@aasm.org.