Appeal type: unknown
Decision: unknown

 
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). 
 
The rules say that all claims submitted to MACs and Durable Medical Equipment (DME) MACs, and 
outpatient facility services claims (Type of Bill 13X, 14X, 85X) are tested against MUEs. UEs 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. Edits based on established 
CMS policies may limit UOS. For example: a) The MUE value for a surgical or diagnostic procedure may be 
based on the bilateral surgery indicator on the Medicare Physician Fee Schedule Database (MPFSDB). (i) If the 
bilateral surgery indicator is 0, a bilateral procedure must be reported with 1 unit of service. There is no 
additional payment for the code if reported as a unilateral or bilateral procedure because of anatomy or 
physiology. Alternatively, the code descriptor may specifically state that the procedure is a unilateral 
procedure, and there is a separate code for a bilateral procedure You can find this guidance in National Correct 
Coding Initiative Chapter 1, Sections A. Introduction and V. Medically Unlikely Edits (MUEs). 
 
Medicare guidance says, CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for 
needle placement by different modalities. CMS payment policy allows one unit of service for any of these 
codes at a single patient encounter regardless of the number of needle placements performed. The unit of 
service for these codes is the patient encounter, not number of lesions, number of aspirations, number of 
biopsies, number of injections, or number of localizations. You can find this guidance in National Correct Coding Initiative Chapter 9, Section G. 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. Medicare guidance says CPT code 77002 has Practitioner Services 
MUE Value: 1 and MUE Adjudication Indicator: 3 Date of Service Edit: Clinical. You can find this guidance 
in the MCR MUE Practitioner Services Effective 04-01-2021. 
 
Medicare guidance says CPT code 77002 has a Bilateral Surgery Indicator of 0. You can find this guidance 
in the 2021 National Physician Fee Schedule July Release 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.