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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.
Medicare guidelines says '"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. Physicians must report
services correctly. This manual discusses general coding principles in Chapter I and principles more relevant to
other specific groups of HCPCS/CPT codes in the other chapters. There are certain types of improper coding
that physicians must avoid. Procedures should be reported with the most comprehensive CPT code that
describes the services performed. Physicians must avoid upcoding. AHCPCS/CPT code may be reported only
if all services described by that code have been performed." "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. Physicians must report services correctly. This manual discusses general coding principles in
Chapter I and principles more relevant to other specific groups of HCPCS/CPT codes in the other chapters.
There are certain types of improper coding hat physicians must avoid. Procedures should be reported with the
most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. A
HCPCS/CPT code may be reported only if all services described by that code have been performed." "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. Physicians must report services correctly. This manual discusses
general coding principles in Chapter I and principles more relevant to other specific groups of HCPCS/CPT
codes in the other chapters. There are certain types of improper coding that physicians must avoid. Procedures
should be reported with the most comprehensive CPT code that describes the services performed. Physicians
must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have
been performed." "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. Physicians must report services
correctly. This manual discusses general coding principles in Chapter I and principles more relevant to other
specific groups of HCPCS/CPT codes in the other chapters. There are certain types of improper coding that
physicians must avoid. Procedures should be reported with the most comprehensive CPT code that describes
the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all
services described by that code have been performed." "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.
Physicians must report services correctly. This manual discusses general coding principles in Chapter I and
principles more relevant to other specific groups of HCPCS/CPT codes in the other chapters. There are certain
types of improper coding that physicians must avoid. Procedures should be reported with the most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. AHCPCS/CPT code may be reported only if all services described by that code have been performed." "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. Physicians must report services correctly. This manual discusses general coding principles in Chapter I and principles more relevant to other specific groups of HCPCS/CPT codes in the other chapters. There are certain types of improper coding that physicians must avoid. Procedures should be reported with the most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed." You can find the guidelines in the Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Action, Section 3.3.2.1-Documents on Which to Base a Determination and National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 1-General Correct Coding Policies, Section A-Introduction, page I-7 and I-8.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.