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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 CPT code 76642 26 LT and 76642 26 RT has a bilateral surgery indicator of "1". You 
can find this guidance in the 2022 National Physician Fee Schedule Relative Value July Release. 
 
Medicare guidance says 1 = 150 percent payment adjustment for bilateral procedures applies. If code is billed 
with the bilateral modifier base payment for these codes when reported as bilateral procedures on the lower of: 
(a) the total actual charge for both sides, or (b) 150 percent of the fee schedule amount for a single code. You 
can find this guidance in the Medicare Claims Processing Manual Chapter 23  Fee Schedule Administration 
and Coding Requirements, Section 50.6.  
 
Medicare guidance says to lower the Medicare Fee-For-Service Paid Claims Error Rate, the CMS has 
established units of service edits referred to as Medically Unlikely Edit(s) (MUEs). 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 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. 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, the CMS began introducing date of service (DOS) MUEs. Over time the 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 a HCPCS/CPT code has an MUE that is adjudicated as a claim line edit, (i.e., MAI equal to 
1) appropriate use of CPT modifiers (i.e., 59 or -X{EPSU}, 76, 77, 91, anatomic) may be used to report the 
same HCPCS/CPT code on 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. (3) 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). 
ii. If the bilateral surgery indicator is 1, a bilateral surgical procedure must be reported with 1 unit of 
service and modifier 50 (bilateral modifier). A bilateral diagnostic procedure may be reported with 1 unit of 
service and modifier 50 on 1 claim line, or 1 unit of service with modifier RT on 1 claim line plus 1 unit of 
service and modifier LT on a second claim line. 
b) The MUE value for a code may be 1 where the code descriptor does not specify a unit of service and the 
CMS considers the default UOS to be per day. You can find the guidance in the National Correct Coding 
Initiative Policy, Chapter I - General Correct Coding Policies, Sec-V- Medically Unlikely Edits. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.