General Question for the Week of June 5, 2017

Question:

Is there an appeal process for units of service (UOS) denied based on medically unlikely edits (MUEs)?

Answer:

UOS denied due to a MUE, whether a claim line MUE or date-of-service MUE, may be appealed. Appeals should be submitted to local contractors, not the MUE contractor. Contractors adjudicating appeals will determine whether:

• The appropriate HCPCS/CPT code is reported
• The appropriate number of UOS is reported
• Whether the UOS reported are medically reasonable and necessary.

Contractors may pay UOS in excess of the MUE value if the contractor determines that they are medically reasonable and necessary.