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 providers 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 effective for claims with dates of service July 1, 2007 and after, the non-Outpatient 
Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be integrated into the OPPS OCE. 
This integration will result in the routing of all institutional outpatient claims, including non-OPPS hospital 
claims, through a single integrated OCE eliminating the need to update two separate OCE software packages 
on a quarterly basis. The integrated OCE does not change the current logic that is applied to outpatient bill 
types that already pass through the OPPS OCE software. It merely expands the software usage to include non-
OPPS hospitals. This new software product will be referred to as the Integrated OCE (I/OCE). The I/OCE 
instructions and specifications are provided via Recurring Update Notifications. They are also posted on the 
Web at the following address 
https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs.  
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 40.1. 
 
The rules say that inpatient-only procedure codes invoke edit 18. A line has a C status indicator and is not on 
the 'separate procedure' list or A line has a C status indicator and is on the 'separate procedure' list, but there 
are no type T lines on the same day. All other line items on the same day as the line with a C status indicator 
are denied and edit 49 is assigned on all line items. This is the only edit that can cause one or more days of a 
multiple day claim to be denied, or single day claim with all lines denied. The disposition for this edit is Line 
Item denial (LID) which means that the individual line is denied for payment, but other lines may be reviewed 
separately. This line item cannot be resubmitted, but it can be appealed. Edit 49, which is applied to services 
reported on the same day as the inpatient-only procedure, returns LID dispositions as well. 
 
The rules say that when a claim consists of a combination of codes that are denied or rejected or have a status 
indicator N. Edit 47 is assigned to all lines with status indicator N, or that change from Q to N, that are not 
already denied or rejected and have no other service on the claim. The disposition for this edit is Line Item 
Rejection (LIR) which means that the individual line items are rejected for payment. This line item can be 
corrected and resubmitted, but it cannot be appealed. 
 
You can find this information in the Integrated OCE Centers for Medicare and Medicaid Services (CMS) 
Specifications V23.3 Effective October 1, 2022. 
 
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.