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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). 
 
Medicare guidance says, Physicians must report services correctly. This manual discusses general coding 
principles in Chapter I, and principles more relevant to other specific groups of HCPCS/CPT codes in the other 
chapters. There are certain types of improper coding that physicians must avoid. All practitioner claims 
submitted to MACs, outpatient facility services claims (Type of Bill 13X, 14X, 85X), and supplier claims 
submitted to Durable Medical Equipment (DME) MACs are tested against MUEs. 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 94002 (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. You can find this guidance in the National Correct Coding Initiative Chapter 1, A. 
Introduction and V. Medically Unlikely Edits (MUEs). 
 Medicare guidance says, CMS National Correct Coding Initiative Program (NCCI) Medicare and Medicaid 
Program - Medically Unlikely Edits (MUEs) are used by the Medicare Administrative Contractors (MACs), 
including Durable Medical Equipment (DME) MACs, to reduce the improper payment rate for Part B claims. 
An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most 
circumstances for a single beneficiary on a single date of service. Not all HCPCS/CPT codes have an MUE. 
You can find this guidance in the CMS.Gov Medically Unlikely Edits. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.