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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 this integrated OCE (IOCE) program processes claims for outpatient institutional 
providers including hospitals that are subject to the Outpatient Prospective Payment System (OPPS) as well as 
hospitals that are not (Non-OPPS). The IOCE 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 IOCE 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. Medicare guidance says 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. 
 
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. Section 6.2 
Edit Descriptions and Reason for Edit Generation Table Edit 15 - Service unit out of range for procedure; The 
maximum units allowed is greater than zero and the sum of the service units for all line items with the same 
procedure code on the same day exceeds the maximum allowed for this procedure and Modifier 91 is not 
present but the HCPCS code is not on the list of laboratory/pathology codes which are exempt from this edit. 
(inactive). Disposition Return to Provider. You can find this guidance in the Integrated OCE (IOCE) CMS 
Specifications V23.1 Effective April 01, 2022, Section 3.1, 6.1, and 6.2.  
 
Medicare guidance says per Addendum B HPCP code 80053 has a status indicator of "Q4". You can find 
this guidance in the cms.gov April 2022 web addendum B. Medicare guidance says per Addendum D1, a status 
indicator of "Q4" - Conditionally packaged laboratory services. Paid under OPPS; Payment is packaged into 
payment for other services, including outliers. Therefore, there is no separate APC payment. You can find this 
guidance in the Addendum D1. Medicare guidance says an OPPS payment status indicator is assigned to every 
HCPCS code. The status indicator identifies whether the service described by the HCPCS code is paid under 
the OPPS and if so, whether payment is made separately or packaged. The status indicator may also provide 
additional information about how the code is paid under the OPPS or under another payment system or fee 
schedule. The full list of status indicators and their definitions is published in Addendum D1 of the OPPS/ASC 
proposed and final rules each year. The status indicator for each HCPCS code is shown in OPPS Addendum B. You can find this guidance in the Medicare Claims Processing Manual Chapter 4 - Part B Hospital (Including 
Inpatient Hospital Part B and OPPS) Section 10.1.1 - Payment Status Indicators. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.