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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 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). You can find 
this information in the National Correct Coding Initiative Policy Manual, Chapter I General Correct Coding 
Policies, A. Introduction. 
 
The rules say that 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=OPPS, 2= 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 information on the Medicare website, CMS.Gov, Outpatient Code Editor (OCE). 
 
The rules say that 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  62, Edit Description  Code not recognized 
by OPPS; alternate code for same service may be available. Reason for Edit Generation  The procedure code 
has a Not recognized by Medicare OPPS indicator. Services with a status indicator of B always return edit 62. 
Disposition  RTP. 7.1.2 APC Return Buffer Table: Status Indicator (SI) B  Non-allowed item or service for 
OPPS CMS.gov, Hospital Outpatient PPS, Addendum B April 2022 Release Date: HCPCS code Q4038  Cast 
sup shrt leg fiberglass has a Status Indicator of B CMS.gov, Hospital Outpatient PPS, Addendum D1
Payment Status Indicators: Indicator B is described as Codes that are not recognized by OPPS when submitted 
on an outpatient hospital Part B bill type (12X and 13X) and are not paid under OPPS. You can find this 
information in Medicare's CMS.gov, Integrated OCE (IOCE) CMS Specifications V23.1, Effective 04/01/2022. 
 
The rules say that 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 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 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. 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. The integrated OCE does not change the current 
logic that is applied to outpatient bill types that already pass through the OPPS OCE software. It merely 
expands the software usage to include non-OPPS hospitals. This new software product will be referred to as the 
Integrated OCE (I/OCE). The following bill types are subject to OPPS: 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 nonpatient laboratory specimens and is no longer applicable for partial 
hospitalization billing. You can find this information in the Medicare Claims Processing Manual Chapter 4 - 
Part B Hospital (Including Inpatient Hospital Part B and OPPS), 10.1  Background, 10.1.1 - Payment Status 
Indicators, 40.1 - Integrated OCE (July 2007 and Later) and 120.1 - Bill Types Subject to OPPS. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.