Thanks a lot that you have put forth such nice question. There are many many coders and billers in Healthcare field who are truly unaware of this and should know the answer of this.
As you are aware of Utilization survey, Comprehensive Error Rate Testing, and many more methods are adopted to check fraudulent practices. OIG/CMS keep an eye on all these fraudulent practices.
At any point of time, if it comes to CMS notice that there is a probability of fraud in billing certain CPTs in the process of their scrutiny be it on national basis or geographical basis, then they follow an internal guidelines on the basis of which they can start rejcting certain percentage of such claims, so as to take time to monitor on the denied claims, and finally they follow certain policy to not to pay in some claims.
This is what not published by CMS anywhere and nor a CMS regulation. This is what is the summary of all the feedbacks that I received from many customer reps over the years, and certainly based on observation only.
The key to attend to such denials:
1. Always chek if any other billing/coding error is there that might have caused the denial.
2. Check previous track record of previous such paid claims or denied claims. Try to figure out the differences between the paid claims and unpaid claims.
Now, you can be in a better position to analyze how to handle the claims with many info at your hands based on observation. Hope, this helps.