Frequency / MUE Units Appeal Letter

Use this when the payer paid some units and denied the rest against a frequency cap or MUE. The denied units are recoverable whenever the chart supports the quantity and the edit is overridable.

What makes it win

• Document the medical necessity for the specific number of units billed
• Confirm the MUE Adjudication Indicator allows an override (MAI 1/3 can be bypassed with support; MAI 2 is an absolute limit)
• Append the appropriate modifier where supported (76/77 for repeats, 59/X{EPSU}, or 91 for repeat labs)
• Split units correctly by date, site, or session so they don't read as one over-limit line

The template

Replace the [BRACKETED] fields with your details. This is the manual version of the appeal Volari files for you automatically.

[PRACTICE LETTERHEAD]
[DATE]

[PAYER NAME] — Appeals Department
[PAYER APPEALS ADDRESS]

RE: Appeal of Frequency / MUE Units Denial (CARC 151 / 273)
Patient: [PATIENT NAME]   Member ID: [MEMBER ID]
Claim #: [CLAIM NUMBER]   Date of Service: [DOS]
CPT/HCPCS: [CPT CODE]   Units billed: [UNITS]   Units denied: [DENIED UNITS]

To the Appeals Department:

We are appealing the denial of [DENIED UNITS] unit(s) of [CPT CODE]. The billed quantity was medically necessary and is supported by the record.

The patient required [UNITS] unit(s) of [CPT CODE] on [DOS] because [CLINICAL JUSTIFICATION — e.g. bilateral procedure, repeat study for a changed condition, dosage per weight]. The enclosed note documents each unit: [SPECIFICS — sites, times, or repeat rationale].

This code's MUE carries Adjudication Indicator [MAI 1 / MAI 3], which permits units above the edit when medical necessity is documented, as it is here. [IF APPLICABLE: Modifier [76/77/91/59] is appended to reflect the [repeat/distinct] service.]

We request the denied units be reprocessed and paid. Please contact [CONTACT NAME] at [PHONE].

Enclosed: office/procedure note dated [DOS][, corrected claim with unit split].

Sincerely,
[BILLING MANAGER NAME], [TITLE]
[PRACTICE NAME] — NPI [NPI]   TIN [TIN]

Common questions

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