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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 state that carriers do not include the services listed below in the payment amount for a procedure with
the appropriate indicator in Field 16 of the MFSDB. These services may be paid for separately.
- The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery.
Please note that this policy only applies to major surgical procedures. The initial evaluation is always
included in the allowance for a minor surgical procedure;
- Services of other physicians except where the surgeon and the other physician(s) agree on the transfer
of care. This agreement may be in the form of a letter or an annotation in the discharge summary,
hospital record, or ASC record;
- Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur
due to complications of the surgery;
- Treatment for the underlying condition or an added course of treatment which is not part of normal
recovery from surgery;
- Diagnostic tests and procedures, including diagnostic radiological procedures;
- Clearly distinct surgical procedures during the postoperative period which are not re-operations or
treatment for complications. (A new postoperative period begins with the subsequent procedure.) This
includes procedures done in two or more parts for which the decision to stage the procedure is made
prospectively or at the time of the first procedure. Examples of this are procedures to diagnose and treat
epilepsy (codes 61533, 61534-61536, 61539, 61541, and 61543) which may be performed in succession
within 90 days of each other;
- Treatment for postoperative complications which requires a return trip to the operating room (OR). An
OR for this purpose is defined as a place of service specifically equipped and staffed for the sole
purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and
an endoscopy suite. It does not include a patient's room, a minor treatment room, a recovery room, or an
intensive care unit (unless the patient's condition was so critical there would be insufficient time for
transportation to an OR);
- If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is
payable separately;
- For certain services performed in a physician's office, separate payment can no longer be made for a
surgical tray (code A4550). This code is now a Status B and is no longer a separately payable service on
or after January 1, 2002. However, splints and casting supplies are payable separately under the
reasonable charge payment methodology;
- Immunosuppressive therapy for organ transplants; and
- Critical care services (codes 99291 and 99292) unrelated to the surgery where a seriously injured or
burned patient is critically ill and requires constant attendance of the physician.
You can find this information in the Medicare Claims Processing Manual, Chapter 12, 40.1
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.