Appeal type: unknown
Decision: unknown

 
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. 
 
The rules say that the Centers for Medicare and Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied. 
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. Codes with an MAI of 3 are based on criteria combined with data such that it would be 
possible, but medically unlikely, that higher values would represent correctly reported medically necessary 
services. To be paid, there must be evidence (e.g., medical review) that the excess units were actually provided, 
were correctly coded, and were medically necessary. You can find this rule in the Centers for Medicare and 
Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 
I(V). 
 
The rules say that the specific characteristics that the lesion must have are as follows: 
 The lesion must meet one or more ABCDE criteria (Asymmetry, Border, Color, Diameter, Evolving) 
 Primary melanocytic skin lesions between 5mm and 19mm 
 Lesions where the skin is intact (i.e. non-ulcerated or non-bleeding lesions) 
 Lesions that do not contain a scar or were previously biopsied 
 Lesions not located in areas of psoriasis, eczema or similar skin conditions 
 Lesions not already clinically diagnosed as melanoma or for which the clinical suspicion is sufficiently 
high that the treating clinician believes melanoma is a more likely diagnosis than not 
 Lesions in areas other than palms of hands, soles of feet, nails, mucous membranes and hair covered 
areas that cannot be trimmed 
 The ordering clinician must also have a plan at the time of ordering the test to continue to monitor the skin 
lesion for changes if the test is negative. The record must also contain a photograph of the lesion at the time 
that the PLA is ordered to allow for appropriate evaluation in subsequent follow-up. Only one test may be used 
per patient per clinical encounter in most cases. In roughly 10% of patients a second test may be indicated for 
the same clinical encounter. For rare cases where more than 2 tests are indicated in a single clinical encounter, 
an appeal with supporting documentation may be submitted for additional tests. You can find this rule in the 
Local Coverage Determination for Molecular Diagnostics (MolDX): Pigmented Lesion Assays, L68151. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.