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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 Palmetto GBA considers FDA-approved prosthetic cervical discs reasonable and necessary
for the treatment of Medicare beneficiaries with symptomatic cervical degenerative disease or herniated disc at
a single level when all of the following criteria are met:

1. The device is approved by the FDA AND
2. The Beneficiary is skeletally mature AND
3. The Beneficiary has EITHER
a. Intractable cervical radicular pain or myelopathy which has failed at least 6 weeks of
conservative non-operative treatment including physician-directed pain management (e.g.
pharmacotherapy addressing neuropathic pain and physical therapy) OR
b. Beneficiary has severe or rapidly progressive symptoms of nerve root or spinal cord
compression requiring hospitalization or immediate surgical intervention, AND
4. The Beneficiary must have clinical evidence of corresponding nerve root or spinal cord compression
documented by computed tomography (CT), myelography, or magnetic resonance imaging (MRI),
AND
5. Cervical degenerative disc disease is from C3 to C7, AND
6. The Beneficiary is free from absolute contraindications to cervical disc replacement (CDR) which
include:
a. Extreme obesity (BMI greater than or equal to 40 kg/m2)
b. Significant cervical anatomical deformity
c. Allergy or sensitivity to implant materials (cobalt, chromium, molybdenum, polyethylene,
titanium)
d. Active systemic infection or infection at the operating site
e. Osteoporosis or osteopenia
f. Marked cervical instability on resting lateral or flexion/extension radiographs demonstrated by
translation greater than 3.5mm, and/or greater than 11o angular difference to that of either level
adjacent the treated level
g. Severe spondylosis
h. Clinically compromised vertebral bodies at affected level
7. Two-level procedures performed simultaneously may be considered reasonable and necessary if there is
objective clinical evidence of radiculopathy, myelopathy or spinal cord compression at two
corresponding contiguous levels. A CDR device FDA-approved for 2 levels is required.

Cervical disc replacement is considered investigational for all other indications and conditions including:

- Disc replacement at 2 non-contiguous levels or 3 or more levels
- Combined use of an artificial cervical disc and fusion
- Prior surgery at the treated level
- Previous fusion at another level
- Any anatomical deformity (e.g. ankylosing spondylitis, trauma)
- Any autoimmune disease or rheumatoid arthritis
- Moderate to severe facet joint arthropathy at the involved level
- Metabolic bone disease (e.g. osteoporosis, Paget's disease, osteomalacia, osteogenesis imperfecta) or
taking medications known to potentially interfere with bone/soft tissue healing (e.g. steroids)
- Malignancy
- Chronic renal failure

You can find this rule in the Local Coverage Determination (LCD): Cervical Disc Replacement (L38033).

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.