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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
Medicare guidance says, Physicians must report services correctly. This manual discusses general coding 
principles in Chapter I, and principles more relevant to other specific groups of Healthcare Common Procedure 
Coding System (HCPCS)/Current Procedural Terminology (CPT) codes in the other chapters. There are certain 
types of improper coding that physicians must avoid. All practitioner claims submitted to MACs, outpatient 
facility services claims (Type of Bill 13X, 14X, 85X), and supplier claims submitted to Durable Medical 
Equipment (DME) MACs are tested against MUEs. MUEs for HCPCS codes with an MAI of 2 are absolute 
date of service edits. These are per day edits based on policy. HCPCS codes with an MAI of 2 have been 
rigorously reviewed and vetted within CMS and obtain this MAI designation because unit of service (UOS) on 
the same date of service (DOS) in excess of the MUE value would be considered impossible because it was 
contrary to statute, regulation, or subregulatory guidance. This subregulatory guidance includes clear correct 
coding policy that is binding on both providers and CMS claims processing contractors. Limitations created by 
anatomical or coding limitations are incorporated in correct coding policy, both in the HIPAA mandated coding 
descriptors and CMS approved coding guidance as well as specific guidance in CMS and NCCI manuals. For 
example, it would be contrary to correct coding policy to report more than one unit of service for CPT 94002 
(Ventilation assist and management . . . initial day) because such use could not accurately describe two initial 
days of management occurring on the same date of service as would be required by the code descriptor. As a 
result, claims processing contractors are instructed that an MAI of 2 denotes a claims processing restriction 
for which override during processing, reopening, or redetermination would be contrary to CMS policy. 
 
Edits based on established CMS policies may limit UOS. For example, a) The MUE value for a surgical or 
diagnostic procedure may be based on the bilateral surgery indicator on the Medicare Physician Fee Schedule 
Database (MPFSDB). ii. If the bilateral surgery indicator is 1, a bilateral surgical procedure must be reported 
with 1 unit of service and modifier 50 (bilateral modifier). You can find this guidance in the National Correct 
Coding Initiative Chapter 1, A. Introduction and V. Medically Unlikely Edits (MUEs). 
 
Medicare guidance says, CMS National Correct Coding Initiative Program (NCCI) Medicare and Medicaid 
Program. Medically Unlikely Edits (MUEs) are used by the Medicare Administrative Contractors (MACs), including Durable Medical Equipment (DME) MACs, to reduce the improper payment rate for Part B claims. 
An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most 
circumstances for a single beneficiary on a single date of service. Not all HCPCS/CPT codes have an MUE. 
You can find this guidance in the CMS.Gov Medically Unlikely Edits. 
 
Medicare guidance says, HCPCS/ CPT Code: 76642. Practitioner Services MUE Values: 1. MUE Adjudication 
Indicator: 2 Date of Service Edit: Policy. You can find this guidance in the MCR MUE Practitioner Services 
Eff 07-01-2022. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.