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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.
The rules say that providers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter I(A). Medicare guidance says "Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in either a rural health professional shortage area (HPSA) as defined by 332(a)(1) (A) of the Public Health Services Act or in a county outside of an MSA as defined by 1886(d)(2)(D) (go to the link and select the applicable title) of the Act. As a condition of payment, you must use an interactive audio and video telecommunications system that permits real-time communication between you, at the distant site, and the beneficiary, at the originating site. Asynchronous "store and forward" technology, the transmission of medical information the physician or practitioner at the distant site reviews at a later time, is permitted only in Federal telemedicine demonstration programs in Alaska or Hawaii." "Section 1848(g)(4) of the Social Security Act requires that (the prescribing provider) submit claims for all your Medicare patients for services rendered. This requirement applies to all physicians and suppliers who provide covered services to Medicare beneficiaries. Per the Medicare reference below: "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." Per the Medicare reference below; "Before submitting a claim to the DME MAC the supplier must have on file a dispensing order, the detailed written order, the CMN (if applicable), the DIF (if applicable), information from the treating physician concerning the patient's diagnosis, and any information required for the use of specific modifiers or attestation statements as defined in certain DME MAC policies. The supplier should also obtain as much documentation from the patient's medical record as they determine they need to assure themselves that coverage criteria for an item have been met. If the information in the patient's medical record does not adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved unless a properly executed ABN of possible denial has been obtained." Per Medicare Program Integrity Manual; "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.". You can find this guidance in the Medicare Claims Processing Manual, Chapter 12 - Physicians/Nonphysician Practitioners, 190 - Medicare Payment for Telehealth Services, Subsection 190.2 - Eligibility Criteria; Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services, Section 270 - Telehealth Services; Medicare Learning Network Booklet - Telehealth Services ICN 901705 February 2018; Government Publishing Office 42 CFR 410.38, Durable Medical Equipment: Scope and Conditions; https://www.gpo.gov/fdsys/granule/CFR-2010-title42-vol2/CFR-2010-title42-vol2-sec410-38; Social Security Act Section 1848(g)(4); 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;
Medicare Program Integrity Manual, Chapter 5 - Items and Services Having Special DME Review Considerations, Section 5.8 - Supplier Documentation, Paragraph A.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.