Exceeding NCD/LCD Maximums

Medicare requires the medical necessity for each service reported, including laboratory testing, to be clearly demonstrated in the patient’s medical record.

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Utilization Guidelines

Some laboratory tests are considered “Medicare Limited Coverage Tests” and can only be covered with specified diagnoses approved by Medicare.

Male physician sits in his office, reviewing patient lab results at his computer.

Understanding Overutilization

Denials on the basis of overutilization arise when certain tests exceed the recommended frequency guidelines set by Medicare and other insurance plans. To navigate frequency limitations effectively, clients are encouraged to refer to the billing section of our website, where they can find a list of common tests denied for frequency. 

If a test is performed more frequently than deemed clinically necessary, it will automatically be denied. Frequency limitations also encompass situations where a set of tests is conducted on the same date of service, a scenario in which Medicare prohibits the simultaneous performance of these tests. 

What if labs were previously performed at a hospital or outpatient setting within the frequency limitation?

Unfortunately, this is a challenging situation, as frequency denials are based on the patient, not the provider. Aculabs cannot bill the patient or the responsible party without an Advance Beneficiary Notice being signed for that specific lab draw instance. This is crucial to avoid what is considered surprise billing.