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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. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. 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(A). 
 
The rules say that CPT code 76642 has a bilateral surgery indicator of "1". You can find this information in the 
2022 National Physician Fee Schedule Relative Value July Release. 
 
The rules say that 1 = 150 percent payment adjustment for bilateral procedures applies. If code is billed with 
the bilateral modifier base payment for these codes when reported as bilateral procedures on the lower of: (a) 
the total actual charge for both sides, or (b) 150 percent of the fee schedule amount for a single code. You can 
find this information in the Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and 
Coding Requirements, Section 50.6.  
 
The rules say that to lower the Medicare Fee-For-Service Paid Claims Error Rate, CMS has established units of 
service edits referred to as Medically Unlikely Edit(s) (MUEs). 
 
An MUE for HCPCS/CPT code is the maximum number of units of service (UOS) under most circumstances 
allowable by the same provider for the same beneficiary on the same date of service. The ideal MUE value for 
a HCPCS/CPT code is the unit of service that allows the vast majority of appropriately coded claims to pass the 
MUE. 
 
All claims submitted to MACs and Durable Medical Equipment (DME) MACs, and outpatient facility services 
claims (Type of Bill 13X, 14X, 85X) are tested against MUEs. 
 
Prior to April 1, 2013, each line of a claim was adjudicated separately against the MUE value for the 
HCPCS/CPT code reported on that claim line. If the UOS on that claim line exceeded the MUE value, the entire claim line was denied. 
 
In the April 1, 2013, version of MUEs, the CMS began introducing date of service (DOS) MUEs. Over time the 
CMS will convert many, but not all, MUEs to DOS MUEs. Since April 1, 2013, MUEs are adjudicated either 
as claim line edits or DOS edits. If the MUE is adjudicate as a claim line edit, the UOS on each claim line are 
compared to the MUE value for the HCPCS/CPT code on that claim line. If the UOS exceed the MUE value, 
all UOS on that claim line are denied. 
 
If a HCPCS/CPT code has an MUE that is adjudicated as a claim line edit, (i.e., MAI equal to "1") appropriate 
use of CPT modifiers (i.e., 59 or -X {EPSU}, 76, 77, 91, anatomic) may be used to report the same 
HCPCS.CPT code on separate lines of a claim. Each line of the claim with that HCPCS/CPT code will be 
separately adjudicated against the MUE value for that HCPCS.CPT code. Claims processing contractors have 
rules limiting use of these modifiers with some HCPCS/CPT codes. 
 
(3) 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). A bilateral diagnostic procedure may be reported with "1" unit of 
service and modifier LT on a second claim line. 
 
(b) the MUE for a code may be "1" where the code descriptor does not specify a unit of service and the CMS 
considers the default UOS to be "per day."  
 
You can find this information in the National Correct Coding Initiative Policy, Chapter I - General Correct 
Coding Policies, Sec-V- Medically Unlikely Edits. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.