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. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code on separate lines of the claim. MUEs for codes with an MAI of 2 are absolute date of service edits. These are "per day edits based on policy." Codes with an MAI of "2" have been rigorously reviewed and vetted within CMS and obtain this MAI designation because units of service 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.  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 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 code J7620 has an I/OCE edit of 72, this code has a status indicator of M. Service is not billable to the contractor. This edit is bypassed when the bill type is 85X and the revenue code is 096X, 097X, or 098X. This edit is also bypassed when the bill type is 81X or 82X and the revenue code is 657. Edit 72 has a disposition of Return To Provider, meaning that there are one or more edits present that cause the whole claim to be returned to the provider. A claim returned to the provider means that the provider can resubmit the claim once the problems are corrected. You can find these rules in Integrated OCE (IOCE) Specifications V22.0.  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.