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Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
Medicare guidance says Unless otherwise specified, the MAC, RAC and ZPIC/UPIC shall request information 
from the billing provider/supplier. The treating physician, another clinician, provider, or supplier should submit 
the requested documentation. However, because the provider selected for review is the one whose payment is 
at risk, it is this provider who is ultimately responsible for submitting, within the established timelines, the 
documentation requested by the MAC, CERT, RAC and ZPIC/UPIC. When information is requested from both 
the billing provider or supplier and a third party and a response is received from one or both that fails to 
support the medical necessity of the service, the MACs and ZPICs/UPICs shall deny the claim, in full or in 
part, using the appropriate denial code. Contractors shall count these denials as medical record reviews. This 
section applies to MACs, CERT, RACs, SMRC and UPICs, as indicated. The MACs, CERT, RACs, SMRC, 
and UPICs shall review any information necessary to make a prepayment and/or postpayment claim 
determination, unless otherwise directed in this manual. This includes reviewing any documentation submitted 
with the claim and any other documentation subsequently requested from the provider or other entity when 
necessary. In certain circumstances it may be appropriate for medical reviewers to consider relevant and 
accessible billing history or other information obtained from the Common Working File (in limited 
circumstances), outcome assessment and information set (OASIS), or the minimum data set (MDS), among 
others. For Medicare to consider coverage and payment for any item or service, the information submitted by 
the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and 
confirm that Medicare coverage criteria have been met. Plans must have processes in place for making timely 
coverage decisions (initial requests and appeals), which includes soliciting clinical documentation, such as 
medical records, when necessary. If a plan does not have enough information to make a pre-service or pre-
benefit coverage decision, it should make reasonable and diligent efforts to obtain all necessary information. 
Plans are only required to conduct outreach to request additional information from a provider if the plan does 
not have all necessary information to make a coverage or appeal decision. In instances when outreach is 
necessary to make a coverage or appeal decision, a minimum of one attempt to obtain additional information is 
sufficient. Plans may adopt best practices for outreach, such as making multiple attempts, using multiple 
methods for requesting information (e.g., telephone, fax, e-mail, etc.), and/or and involving plan physicians in 
order to increase the likelihood of obtaining necessary information. If the plan does not receive any additional 
information, the plan should make the best decision it can based on the information available within the 
required adjudication timeframes. Plans are not required to conduct outreach prior to denying claims payments 
if they believe they have all the necessary information needed to make a coverage decision. You can find this 
guidance in the Medicare Program Integrity Manual Chapter 3 - Verifying Potential Errors and Taking 
Corrective Actions, Section 3.2.3.3 - Third-party Additional Documentation Request and Section 3.3.2.1 - 
Documents on Which to Base a Determination and Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance 10.6 - Outreach for Additional Information to Support Coverage 
Decisions. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.