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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. 
 
Medicare guidance says Medicare guidance says An MUE for a HCPCS/CPT code is the maximum number of 
units of service (UOS) under most circumstances allowable by the same provider for the same beneficiary on 
the same date of service. The ideal MUE value for a HCPCS/CPT code is the unit of service that allows the 
vast majority of appropriately coded claims to pass the MUE. 
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. 
Prior to April 1, 2013, each line of a claim was adjudicated separately against the MUE value for the 
HCPCS/CPT code reported on that claim line. If the UOS on that claim line exceeded the MUE value, the 
entire claim line was denied. In the April 1, 2013, version of MUEs, CMS began introducing date of service 
(DOS) MUEs. Over time CMS will convert many, but not all, MUEs to DOS MUEs. Since April 1, 2013, 
MUEs are adjudicated either as claim line edits or DOS edits. If the MUE is adjudicated as a claim line edit, the 
UOS on each claim line are compared to the MUE value for the HCPCS/CPT code on that claim line. If the 
UOS exceed the MUE value, all UOS on that claim line are denied. If the MUE is adjudicated as a DOS MUE, 
all UOS on each claim line for the same date of service for the same HCPCS/CPT code are summed, and 
the sum is compared to the MUE value. If the summed UOS exceed the MUE value, all UOS for the 
HCPCS/CPT code for that date of service are denied. Denials due to claim line MUEs or DOS MUEs may be 
appealed to the local claims processing contractor. DOS MUEs are used for HCPCS/CPT codes where it would 
be extremely unlikely that more UOS than the MUE value would ever be performed on the same date of 
service for the same patient. 
The MUE files on the CMS NCCI website display an MUE Adjudication Indicator (MAI) for each 
HCPCS/CPT code. An MAI of 1 indicates that the edit is a claim line MUE. An MAI of 2 or 3 indicates 
that the edit is a DOS MUE. If a HCPCS/CPT code has an MUE that is adjudicated as a claim line edit, 
appropriate use of CPT modifiers (e.g., 59, 76, 77, 91, anatomic) may be used to report the same separate lines 
of a claim. Each line of the claim with that HCPCS/CPT code will be separately adjudicated against the MUE 
value for that HCPCS/CPT code. Claims processing contractors have rules limiting use of these modifiers with 
some HCPCS/CPT codes. 
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. 
MUEs for HCPCS codes with an MAI of 3 are per day edits based on clinical benchmarks. MUEs assigned 
an MAI of 3 are based on criteria (e.g., nature of service, prescribing information) combined with data such 
that it would be possible but medically highly unlikely that higher values would represent correctly reported 
medically necessary services. If contractors have evidence (e.g., medical review) that UOS in excess of the 
MUE value were actually provided, were correctly coded and were medically necessary, the contractor may 
bypass the MUE for a HCPCS code with an MAI of 3 during claim processing, reopening, or 
redetermination, or in response to effectuation instructions from a reconsideration or higher level appeal. You 
can find this guidance in the NCCI Policy for Medicare Services Chapter 1 General Correct Coding Policies 
Section V and CMS MUE Table. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.