Medically Unlikely Edits (MUE) Revisions Addendum

Policy ID: NDRP-GC-017 Medically Unlikely Edit (MUE) Revision Addendum
Section: Medically Unlikely Edits Revision Addendum
Effective Date: July 01, 2018
Last Reviewed: October 23, 2019


This addendum outlines the Medically Unlikely Edit (MUE) deviations from the CMS MUE values.

Below is the listing of the Plan’s Professional (codes submitted on a CMS-1500 Claim Form) MUEs that differ from the CMS values.

Code Description MUE Effective Date
95165 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy, single or multiple antigens None 04/01/2019
96137 Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; each additional 30 minutes 17 01/01/2019
96139 Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; each additional 30 minutes 17 01/01/2019
A0425 Ground Mileage, per statute mile None 07/01/2018
A0435 Fixed wing air mileage, per statute mile None 07/01/2018
A0436 Rotary wing air mileage, per statute mile None 07/01/2018
J0696 Injection, Ceftriaxone Sodium, per 250 mg 42 07/01/2018
J7186 Injection, Antihemophilic Factor VIII/Von Willebrand Factor Complex (Human), per factor VIII IU 50,000 07/01/2018
J0202 Injection, Alemtuzumab, 1 mg 41 07/01/2018
J0295 Injection, Ampicillin Sodium/Sulbactam Sodium, per 1.5 gm 18 07/01/2018
J0461 Injection, Atropine Sulfate, 0.01 mg 100,000 07/01/2018
J0690 Injection, Cefazolin Sodium, 500 mg 24 07/01/2018
J0743 Injection, Cilastatin sodium, Imipenem, per 250 mg 54 07/01/2018
J0744 Injection, Ciprofloxacin for intravenous infusion, 200 mg 20 07/01/2018
J0878 Injection, Daptomycin, 1 mg 2,000 07/01/2018
J1000 Injection, Dep-estradiol Cypionate, up to 5 mg 5 07/01/2018
J1040 Injection, Methylprednisolone Acetate, 80 mg 51 07/01/2018
J1559 Injection, Immune Globulin (Hizentra), 100 mg 536 07/01/2018
J1580 Injection, Garamycin, Gentamicin up to 80 mg 17 07/01/2018
J1726 Injection, Hydroxyprogesterone Caproate, (Makena), 10 mg 100 07/01/2018
J2543 Injection, Piperacillin Sodium/Tazobactam Sodium, 1 gram/0.125 grams (1.125 grams) 24 07/01/2018
J2675 Injection, Progesterone, per 50 mg 10 07/01/2018
J2787 Injection, Riboflavin 5’-phosphate, ophthalmic solution, up to 3 ml
2 10/01/2019
J2790 Injection, RHO (D) Immune Globulin, Human, Full Dose, 300 mg 5 07/01/2018
J3370 Injection, Vancomycin HCL, 500 mg 25 07/01/2018
J3475 Injection, Magnesium Sulfate, per 500 mg 200 07/01/2018
J3590 Injection, Unclassified biologics None 07/01/2018
J7190 Injection, Factor VIII (Antihemophilic Factor, Human) per IU 33,500 07/01/2018
J9060 Injection, Cisplatin, powder or solution, 10 mg 54 07/01/2018
J9260 Injection, Methotrexate sodium, 50 mg 798 07/01/2018
J7200 Injection, Factor IX (Antihemophilic Factor, Recombinant), Rixubis, per IU 40,250 07/01/2018
J7205 Injection, Factor III FC Fusion (Recombinant), per IU 28,250 07/01/2018
J7187 Injection, Von Willebrand Factor Complex (Humate-P), per IU VWF:RCO 36,000 07/01/2018
J7207 Injection, Factor VIII (Antihemophilic Factor, Recombinant) Pegylated, 1 IU 24,250 07/01/2018
J7180 Injection, Factor XIII (Antihemophilic Factor, Human), per 1 IU 7,000 07/01/2018
J7181 Injection, Factor XIII A-subunit, (Recombinant), per 1 IU 5,000 07/01/2018
J7188 Injection, Factor VIII (Antihemophilic Factor, Recombinant), (Obizur), per IU 161,000 07/01/2018
J7209 Injection, Factor VIII, (Antihemophilic Factor, Recombinant), (NUWIQ), 1 IU 26,500 07/01/2018
J7178 Injection, Human Fibrinogen Concentrate, not otherwise specified, 1 mg 9,900 07/01/2018
J7195 Injection, Factor IX (Antihemophilic Factor, Recombinant) per IU, not otherwise specified 35,000 07/01/2018
J7179 Injection, Von Willebrand Factor (Recombinant), (Vonvendi), 1 IU VWF:RCO 27,300 07/01/2018
J7202 Injection, Factor IX, Albumin Fusion Protein, (Recombinant), Idelvion, 1 IU 13,500 07/01/2018
J7201 Injection, Factor IX, FC Fusion Protein (Recombinant), per IU 27,000 07/01/2018
J7189 Injection, Factor VIIA (Antihemophilic Factor, Recombinant), per 1 microgram 145,000 07/01/2018
J7194 Injection, Factor IX, Complex, per IU 20,500 07/01/2018
J7192 Injection, Factor VIII (Antihemophilic Factor, Recombinant) per IU, not otherwise classified 31,000 07/01/2018
J7193 Injection, Factor IX (Antihemophilic Factor, Purified, non-recombinant), per IU 27,000 07/01/2018
J7183 Injection, Von Willebrand Factor Complex (Human), Wilate, 1 IU VWF:RCO 16,500 07/01/2018
J7198 Injection, Anti-inhibitor, per IU 27,000 07/01/2018
Q9966 Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml 350 07/01/2018
V2520 Contact Lens Hydrophilic, Spherical, per lens None 07/01/2018
V2521 Contact Lens Hydrophilic, Toric, or Prism Ballast, per lens None 07/01/2018
V2522 Contact Lens Hydrophilic, Bifocal, per lens None 07/01/2018
V2523 Contact Lens Hydrophilic, Extended wear, per lens None 07/01/2018


Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.