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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 guidance says "410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. (a) Ordering diagnostic tests. All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary." Also, "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, itis this provider who is ultimately responsible for submitting, within the established timelines, the documentation requested by the MAC, CERT, RAC and ZPIC/UPIC. To prevent denials, the following conditions must be met: 1. Laboratory tests must be ordered by the physician or NPP who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Test not ordered by the physician or NPP who is treating the beneficiary are not reasonable and necessary. 2. The physician or qualified NPP who ordered the test must maintain documentation of medical necessity in the beneficiary's medical record. 3. Entities submitting a claim must maintain documentation received from the ordering physician or NPP. Examples of documentation that may be requested for medical review of claims for laboratory tests are: 1. Clinical evaluations, physician evaluations, consultations, progress notes, physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation is maintained by the physician and/or provider. 2. Supplier/lab notes include all documents that are submitted by suppliers, and labs in support of the claim. 3. Other documents include any records needed from a biller in order to conduct a review and reach a conclusion about the claim." "Documentation Requirements -1. The physician who treats a beneficiary must order all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests for a specific medical problem. The physician uses the results to manage the beneficiary's specific medical problem and may furnish a consultation. Tests not ordered by the physician are not considered reasonable and necessary. 2. The physician should clearly indicate all tests to be performed (for example, "run labs" or "check blood" by itself does not support intent to order) when completing progress notes. 3. Documentation in the patient's medical record must support the medical necessity for ordering the service(s) per Medicare regulations and applicable Local Coverage Determinations (LCDs). Submit these medical records if they are requested. 4. Keep these records available to submit upon request: Progress notes or office notes, Physician order or intent to order, For more information about signature requirements and attestation statements, refer to the Medicare Simplifying Documentation Requirements webpage or Complying with Medicare Signature Requirements." You can find this guidance in the 42 CFR Part 410 Medicare Program; Negotiated Rule making: Coverage and Administrative Policies for Clinical Diagnostic Laboratory Services; Final Rule; 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 3.2.4 - Use of Claims History Information in Claim Payment Determinations, MLN Matters ICN 909407 February 2018 -Provider Compliance Tips For Laboratory Tests and MLN Matters ICN 909221 August 2018 - Complying With Documentation Requirements For Laboratory Services.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.