Internal Audits

Medically Unlikely Edits are a cost saver for insurance companies, but for post-mastectomy providers, they can adversely affect quality care.

What exactly are Medically Unlikely Edits (MUEs) and why do we need to stay on top of their numbers?

Originally, the Centers for Medicare and Medicaid (CMS) developed Medically Unlikely Edits (MUEs) on January 1, 2007, in an effort to reduce the paid claims error rate for Part B claims.  Medically Unlikely Edits are applicable to Private Insurers as well as CMS Carriers, Fiscal Intermediaries, and the Durable Medical Equipment Medical Administrative Contractors (DME MACs A, B, C, D).

A Medically Unlikely Edit for an HCPCS code is preprogrammed into a payors billing and analysis software.

It is the maximum number of units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.  This is NOT a limit on the number of units of service, but a number that the insurer deems reasonable and necessary and over which triggers a review.

medically unlikely edits claims submission

This is where the misunderstanding of “how many bras Medicare pays for, originated.” The MUE for bras for Medicare for a long time has been “6.” Many state payors have a MUE of “2” for bras.

But Not all HCPCS codes have a Medically Unlikely Edit. And although CMS and other insurance payors published most MUE values, other MUE values are confidential and are for CMS and CMS Contractors’ use only.

Also, each DME MAC Jurisdiction, A, B, C, and D, can have different MUEs which adds to the confusion.

MUEs are a cost-saving factor, but having these relatively unknown, statically derived “maximum number of services” has unintended consequences that affect both the provider and the patient. 

Note:  AABCP has assigned a committee with the purpose of researching and requesting reconsideration of MUEs for post-mastectomy products. (06/22)

Published CMS MUE List for post-mastectomy HCPCS codes effective July 1, 2022.