Appeals

20.9.3 – Appeals (Rev. 13216; Issued:05-09-25; Effective: 06-03-25; Implementation:06-03-25) When a request for review is received as a result of an initial determination based on a correct coding initiative edit, and after determining that the reviews were coded correctly, the reviewer must come to the same conclusion as the initial determination (i.e., the review does not result in an increase in payment). If the review determines that a correct coding modifier not submitted with the initial claim could have been appended to either code of an edit code pair, the reviewer may change the initial determination only if the correct coding initiative edit has a modifier indicator of “1.” If the correct coding initiative edit modifier indicator is a “0,” the reviewer must come to the same conclusion as the initial determination. If the conclusion is the same as the initial determination, the review determination must repeat the generic language that appears in the Medicare Summary Notice (MSN) or remittance advice notice pertaining to the correct coding edit. In addition, MACs must include the more detailed explanation of the correct coding initiative edit which can be found in the standard correspondence language for MACs in the Medicare NCCI Correspondence Language Manual on the Medicare NCCI Edits webpage. • MUEs are set high enough to allow for medically likely daily frequencies of services provided in most settings. Because MUEs are based on current coding instructions and practices, MUEs are prospective edits applicable to the time period for which the edit is effective. A change in an MUE is not retroactive and has no bearing on prior services unless specifically updated with a retroactive effective date. In the unusual case of a retroactive MUE change, MACs are not expected to identify claims but should reopen impacted claims that providers or suppliers bring to their attention. • Since MUEs are auto-deny edits, denials may be appealed. Appeals shall be submitted to the appropriate MAC not the NCCI contractor. MACs adjudicating an appeal for a claim denial for a HCPCS/CPT code with an MAI of “1” or “3” may pay correctly coded correctly counted medically necessary UOS in excess of the MUE value. • A denial of services due to an MUE is a coding denial, not a medical necessity denial. The presence of an ABN shall not shift liability to the beneficiary for UOS denied based on an MUE. If during reopening or redetermination medical records are provided with respect to an MUE denial for an edit with an MAI of “3”, MACs will review the records to determine if the provider or supplier actually furnished units in excess of the MUE, if the codes were used correctly, and whether the services were medically reasonable and necessary. If the units were actually provided, but one of the other conditions is not met, a change in denial reason may be warranted (for example, a change from the MUE denial based on incorrect coding to a determination that the item/service is not reasonable and necessary under section 1862(a)(1)). This may also be true for certain edits with an MAI of “1.” The CMS interprets the notice delivery requirements under Section 1879 of the Social Security Act (the Act) as applying to situations in which a provider or supplier expects the initial claim determination to be a reasonable and necessary denial. Consistent with NCCI program guidance, denials resulting from MUEs are not based on any of the statutory provisions that give liability protection to beneficiaries under section 1879 of the Social Security Act. Thus, ABN issuance based on an MUE is NOT appropriate. A provider or supplier may not issue an ABN in connection with services denied due to an MUE and cannot bill the beneficiary for UOS denied based on an MUE. • If a procedure is performed bilaterally and the HCPCS/CPT code descriptor does not state that it is a unilateral or bilateral procedure, report bilateral surgical procedures on a single claim line with modifier 50 and one (1) unit of service. For specific instructions for Ambulatory Surgical Centers, see the Medicare Claims Processing Manual, Chapter 14, Section 40.5. When modifier 50 is required by manual or coding instructions, claims submitted with 2 lines or 2 units and anatomic modifiers will be denied for incorrect coding. MACs may reopen or allow resubmission of those claims in accordance with their policies and with the policy in the Medicare Claims Processing Manual, Chapter 34, Section 10.1. Clerical errors (which include minor errors and omissions) may be treated as reopenings. • Providers or suppliers may change and resubmit their own claims where possible but during reopening MACs may, when necessary, correct the claim to modifier 50 from an equivalent 2 units of bilateral anatomic modifiers. The original submitted version of the claim is retained in the Medicare IDR (Integrated Data Repository). • Providers or suppliers shall use anatomic modifiers (e.g., RT, LT, FA, F1-F9, TA, T1-T9, E1-E4) and report procedures with differing modifiers on individual claim lines when appropriate. Many MUEs are based on the assumption that correct modifiers are used. • A/B MACs shall include with the review determination the more detailed explanation of the correct coding initiative edit, which can be found in the standard correspondence language for A/B MACs in the Medicare NCCI Correspondence Language Manual. • MACs shall assign MSN 15.6. CARC 151 with Group Code CO for claims that fail the MUE edits, when the UOS on the claim exceeds the MUE value, and deny the entire claim line(s) for the relevant HCPCS/CPT code.