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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 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 National Correct Coding Initiative 
(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.