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. 
 
Medicare guidance says, "In this Manual many policies are described utilizing the term physician. Unless 
indicated differently the usage of this term does not restrict the policies to physicians only but applies to all 
practitioners, hospitals, providers, or suppliers eligible to bill the relevant HCPCS/CPT codes pursuant to 
applicable portions of the Social Security Act (SSA) of 1965, the Code of Federal Regulations (CFR), and 
Medicare rules. Providers reporting services under Medicares hospital outpatient prospective payment system 
(OPPS) shall report all services in accordance with appropriate Medicare Internet-only Manual (IOM) 
instructions. Procedures shall be reported with the most comprehensive CPT code that describes he services 
performed. You can find this guidance in the National Correct Coding Initiative Policy Manual, Chapter I 
General Correct Coding Policies, Section A, Introduction. 
 
Medicare guidance says" The 'integrated' Outpatient Code Editor (I/OCE) program processes claims for all 
outpatient institutional providers including hospitals that are subject to the Outpatient Prospective Payment 
System (OPPS) as well as hospitals that are NOT (Non-OPPS). Claim will be identified as 'OPPS' or 'Non-
OPPS' by passing a flag to the OCE in the claim record, 1 equals OPPS, 2 equals Non-OPPS; a blank, zero, or 
any other value is defaulted to 1. The OCE not only identifies individual errors but also indicates what actions 
should be taken and the reasons why these actions are necessary. In order to accommodate this functionality, 
the OCE is structured to return lists of edit numbers. This structure facilitates the linkage between the actions 
being taken, the reasons for the actions and the information on the claim (e.g., a specific diagnosis) that caused 
the action. You can find this guidance in the Medicare web site, CMS.gov, Outpatient Code Editor (OCE). 
 
Medicare guidance says, certain skin substitute products are separately paid, based on their standard SI/APC 
assignment, only when billed with specified skin substitute application procedure codes. If one of the specified 
application procedure codes is not present on the same date of service as the skin substitute, the skin substitute 
product is packaged (has its SI changed to N), the submission of certain skin substitute application procedures 
requires the reporting of a skin substitute product for the same day. Certain skin substitute application 
procedures and skin substitute products are divided into two lists based on high or low cost. Claims containing 
a high cost skin substitute application procedure without any of the high cost skin substitute product codes, and 
conversely any low cost skin substitute application procedure without a low cost skin substitute product code 
for the same day, are returned to the provider (edit 87). (See HCPCS map within the data files for products flagged as high or low cost skin substitutes.) Effective 10/1/2015, if a skin substitute product code is present 
with line item action flag value of 2 representing an external line item denial, the line is not ignored by the 
IOCE for the purposes of applying edit 87. If the denied skin substitute product is on the list of skin substitute 
products and the skin substitute application procedure is also present, edit 87 is not returned. 
 
6 Edit Application within the IOCE 
6.1 Introduction to Edits 
As specified in the introduction to the IOCE, one of the three major functions provided by the IOCE is the 
application of edit(s) to identify errors. Each edit is unique, as it directly links the reason the edit is returned, 
any related information at the line or claim level, and the action required indicated by the edit disposition. For 
example, an edit can cause a line item rejection or return the claim to the provider. It is possible for a claim to 
have one or more edits in all 6 dispositions. The table below lists and describes each edit disposition 6.1.1 Edit 
Dispositions Table Disposition  Claim Return to Provider (RTP), Description  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. 
 
6.2 Edit Descriptions and Reason for Edit Generation Table 
Edit  87, Edit Description  Skin substitute applications procedure without appropriate skin substitute product 
code, Reason for Edit Generation  A List A skin substitute application procedure is submitted without a list A 
skin substitute product; or a list B skin substitute application procedure is submitted without a list B skin 
substitute product on the same date of service. See Skin Substitute Editing and Processing logic for more 
information. Disposition  RTP. You can find this guidance on the Medicare web site, CMS.gov, OCE 
Quarterly Release Files, Integrated OCE (IOCE).  
 
Medicare guidelines says" Section 1833(t) of the Social Security Act (the Act) as amended by Section 4533 of 
the Balanced Budget Act (BBA) of 1997, authorizes CMS to implement a Medicare PPS for: Hospital 
outpatient services, including partial hospitalization services; 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. 
 
All outpatient hospital Part B bills (bill types 12X, 13X with condition code 41 14X and 13X without condition 
code 41) with the exception of bills from hospitals in Maryland, Indian Health Service, CAHs, hospitals located 
in Saipan, American Samoa, the Virgin Islands and Guam; and hospitals that provide Part B only services to 
their inpatients. Effective 4/1/06 the 14X type of bill is for non-patient laboratory specimens and is no longer 
applicable for partial hospitalization billing. You can find this guidance in the Medicare Claims Processing 
Manual, Chapter 4 -Part B Hospital, Section 10- Hospital Outpatient Prospective Payment System (OPPS), 
Section 10.1-Background, Section 40.1-Integrated OCE (July 2007 and Later) and Section 120.1- Bill Types 
Subject to OPPS. Medicare guidance says Data HCPCS HCPCS/CPT 15275 Skin Substitute Proc Low  0. 
You can find the guidance in the CMS.gov, OCE Quarterly Release Files, Data HCPCS Excerpt. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.