Runs in your browser against the CMS tables. The code you look up is recorded for site analytics; the units you enter are not. Drug names come from the CareCost catalog where the code is in it.
A Medically Unlikely Edit is the maximum number of units of a HCPCS or CPT code that Medicare will pay for one patient on one date of service (or, for a minority of codes, on one claim line). CMS sets it from the prescribing information, clinical data and its own policy, publishes it quarterly, and every Medicare contractor applies it automatically. Units above the limit deny; whether the excess can be paid on appeal depends on the code’s adjudication indicator, shown in the lookup above.
Three things decide whether a claim clears the edit. The limit is in billing units of the code, not milligrams — J0897 (denosumab) is priced per 1 mg, so its limit of 120 is 120 mg a day, exactly one Xgeva dose or two Prolia doses; J1745 (infliximab) is per 10 mg, so 150 units is 1,500 mg. Convert the dose to units before comparing.
The table matters because CMS keeps two: practitioner services and outpatient hospital services. 259 of the 1,411 codes here differ between them. The administration codes show it plainly — a therapeutic infusion (96365) is 1 per day in the office and 2 in the hospital outpatient department, and each additional hydration hour (96361) is 8 versus 24. A CMS-1500 is adjudicated on the practitioner table, a UB-04 on the facility table.
The MUE adjudication indicator (MAI) says how the limit is applied. MAI 1 is a claim-line edit: each line is checked on its own, so the same code on a second line with an appropriate modifier is considered separately. MAI 2 is a date-of-service edit based on policy: all lines for the date are summed and the limit is absolute, because CMS considers a higher count anatomically or clinically impossible or contrary to a statute. MAI 3 is a date-of-service edit based on clinical benchmarks: lines are summed, but medically necessary units above the limit can be paid on appeal with documentation. On this table 1,316 codes are MAI 3, 60 are MAI 2 and 35 are MAI 1 — so for almost every drug the limit is a documentation threshold, not a ceiling.
Where all 1,411 limits come from, by CMS’s stated rationale (practitioner table):
| Rationale | Codes |
|---|---|
| Prescribing Information | 648 |
| Clinical: Data | 261 |
| CMS Policy | 144 |
| Code Descriptor / CPT Instruction | 76 |
| Anatomic Consideration | 70 |
| Clinical: CMS Workgroup | 65 |
| Drug discontinued | 37 |
| Oral Medication; Not Payable | 35 |
| Compounded Drug Policy | 33 |
| Clinical: Society Comment | 18 |
| Nature of Service/Procedure | 17 |
| Nature of Equipment | 6 |
| Nature of Analyte | 1 |
For date-of-service edits the discarded-drug line counts. A 100 mg single-dose vial of which 70 mg is given and 30 mg discarded is billed as 70 units plus 30 units on a JW line, and both lines are summed for the date — 100 units against the limit. CMS sets most drug limits from the largest single-dose container or the highest labeled daily dose for that reason, which is why a claim built from whole vials rarely trips the edit while a claim with a transcription error in the units column (mg typed where units belong) trips it immediately.
Weight-based dosing is the other honest way to exceed a limit. A 120 kg patient on 10 mg/kg infliximab needs 1,200 mg, 120 units of J1745 against a limit of 150 — clear. A CAR-T conditioning regimen, a pediatric enzyme replacement or a loading dose can exceed a limit that was set for maintenance dosing; those are MAI 3 appeals with the weight, the order and the label in the record, not coding errors.
159 codes on the practitioner table carry an MUE of 0, and CMS’s own rationale sorts all but one of them into four groups: codes CMS pays only in another setting or under another benefit (“CMS Policy”, 53 codes — 96376 is the one that costs practices money: the additional push of the same drug is 0 on the practitioner table and 10 on the facility table because CPT reserves it for facilities), discontinued products (37), oral drugs billed under a J-code (“Oral Medication; Not Payable”, 35 — Part B does not pay them outside the specific oral anti-cancer and antiemetic benefits), and compounded drugs (33, not payable as separately identifiable products). A 0 is not appealed; the claim is rebuilt.
| Rationale behind the 159 zero-limit codes | Codes |
|---|---|
| CMS Policy | 53 |
| Drug discontinued | 37 |
| Oral Medication; Not Payable | 35 |
| Compounded Drug Policy | 33 |
| Clinical: CMS Workgroup | 1 |
The CareCost Clearance corpus reads each payer’s medical policy and extracts its quantity and dose limits by drug and indication — the rule the payer’s prior-authorization team actually applies. Enter a drug code above to see how many payers limit it and which ones; each payer’s own limit, with its coverage criteria and prior-auth requirements, is in the free trial.
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Free 30-day trial, no card. The MUE lookup stays free.
No. An MUE is a claims edit on billed units per date of service, built by CMS from prescribing information, clinical data and policy. It says nothing about what a physician may order. When a medically necessary dose exceeds an MAI 3 limit, the units are payable on appeal with documentation; the 60 MAI 2 codes on this table are the ones where CMS treats the limit as absolute.
Yes, for date-of-service edits (MAI 2 and 3, which cover all but a few dozen codes here). The administered line and the JW line for the discarded amount are summed for the date, so a 100-unit vial billed as 70 administered + 30 JW is 100 units against the limit. That is why the limit is usually set at or above the largest single-dose container.
CMS publishes separate tables for practitioner services and for outpatient hospital services, and 259 of the 1,411 codes here carry a different value on each. Administration codes are the visible case: 96365 is 1 per day in the office and 2 in the hospital outpatient department, 96361 is 8 and 24. A physician office claim is adjudicated on the practitioner table, a UB-04 on the facility table.
That CMS will not pay the code under the circumstances the table describes. 159 codes on the practitioner table are 0: oral drugs billed under a J-code (not payable under Part B), discontinued products, and 96376, which is a facility-only add-on. A 0 is not a limit to appeal; it is a code that belongs on a different claim or not at all.
No. Most commercial payers apply NCCI edits, but each also publishes its own quantity or dose limits in its medical policy for the drug, and those are usually tighter and indication-specific. The lookup above shows how many payers in the CareCost Clearance corpus carry their own limit on a code, with one example; the full per-payer list is in the trial.
MCR_MUE_PractitionerServices_Eff_07-01-2026.csv) and outpatient hospital services table (MCR_MUE_OutpatientHospitalServices_Eff_07-01-2026.csv), effective 2026-07-01 — cms.gov.