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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 CPT code 64635-RT and 64635-LT has a bilateral surgery indicator of "1". HCPCS-64636-RT, 
64636-59, LT, 64636-59, LT and 64636-59, LT, Global Days- ZZZ. You can find this information in the 2021 
National Physician Fee Schedule Relative Value July Release. 
 
The rules say 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. If code is 
reported a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral 
adjustment before applying any applicable multiple procedure rules. 
 
Field # & Item-16 Global Surgery, this field provides the postoperative time frames that apply to payment for 
each surgical procedure or another indicator that describes the applicability of the global concept to the service. 
ZZZ = Code related to another service and is always included in the global period of the other service. (Note: 
Physician work is associated with intra-service time and in some instances the post service time.) You can find 
this information in the Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and 
Coding Requirements, Section 50.6  Physician Fee Schedule Payment Policy Indicator File Record Layout. 
 
The rules say 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 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 64635-RT and 64635-LT (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. If the bilateral 
surgery indicator is 1, If the bilateral surgery indicator is 1, The bilateral surgical procedure must be 
reported with 1 unit of service and modifier 50 (bilateral modifier), on one claim line. There is no additional 
payment for the code if reported as a unilateral or bilateral procedure because of anatomy or physiology. 
Alternatively, the code descriptor may specifically state that the procedure is a unilateral procedure, and there 
is a separate code for a bilateral procedure. You can find this information in the National Correct Coding 
Initiative Policy, Chapter 1 - General Correct Coding Policies, Sec-V -Medically Unlikely Edits. 
 
The rules say An AOC is a HCPCS/CPT code that describes a service that, with rare exception, is performed in 
conjunction with another primary service by the same practitioner. An AOC is rarely eligible for payment if it 
is the only procedure reported by a practitioner. Add-on codes may be identified in three ways: 
1. The code is listed in this CR or subsequent ones as a Type I, Type II, or Type III add-on code. 
2. On the Medicare Physician Fee Schedule Database an add-on code generally has a global surgery period of 
"ZZZ". 
3. In the CPT Manual an add-on code is designated by the symbol "+". The code descriptor of an add-on code 
generally includes phrases such as "each additional" or "(List separately in addition to primary procedure)." 
CMS has divided the add-on codes into three groups to distinguish the payment policy for each group. 
1. Type I - A Type I add-on code has a limited number of identifiable primary procedure codes. The CR lists 
the Type I add-on codes with their acceptable primary procedure codes. A Type I add-on code, with one 
exception, is eligible for payment if one of the listed primary procedure codes is also eligible for payment to 
the same practitioner for the same patient on the same date of service. Claims processing contractors must 
adopt edits to assure that Type I add-on codes are never paid unless a listed primary procedure code is also 
paid. Final Complete File of Add-On Code for Medicare, Type I-Cpt Manual, HCPCS Manual, And Or CMS 
Policy Defines All Acceptable Primary Codes: For Add-on code-64636-RT, 64636-59, LT, 64636-59, LT and 
64636-59, LT; appropriate Primary Codes 64635. You can find this information in CMS.GOV Add-on Code 
Edits. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.