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Medicare MUE Drug Denials

As we reported earlier, oncology practices in Washington and nationwide are experiencing Medicare denials on several drugs based on the Centers for Medicare and Medicaid Services (CMS) Medically Unlikely Edits* (MUEs).

For those of you unfamiliar with the MUEs, these are edits developed by CMS to reduce the paid claims error 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.  The MUE files are updated on a quarterly basis and posted on the CMS website although not every HCPCS/CPT code has an MUE and due to fraud and abuse concerns, some MUEs are not published. A claim line denial due to an MUE may be appealed, MUE denials are a coding denial not a medical necessity denial.

According to CMS, the units of service for each MUE is set high enough to allow for medically likely daily frequencies of services provided in most settings. However, practices are experiencing denials of certain drugs based on the units of service exceeding the MUE values implemented on January 1, 2011.

WSMOS members reported MUE denials for the following drugs:

Flourouracil   (J9190 500mg)

Fulvestrant   (J9395 25mg)

Epoetin alfa  (J0885 1000u)

WSMOS immediately contacted ASCO (the American Society of Community Oncology) and made them aware of this issue.

 In response, the CMS MUEs for fulvestrant (J9395) and flourouracil (J9190) have been successfully contested. The MUE values for these drugs were adjusted in the most recent MUE file dated 4/1/2011, the new MUE values will be retroactive to 1/1/2011.