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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 a contract plan provider is an agent of the plan. Services and referrals obtained from a plan 
provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan 
provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, 
the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.  
 
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or 
item is never covered, the plan does not have to hold the enrollee harmless.  
 
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone 
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. 
You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 160. 
 
The rules also say that the term "screening mammography" means a radiologic procedure provided to an 
asymptomatic woman for the purpose of early detection of breast cancer and includes a physician's 
interpretation of the results of the procedure.  Unlike diagnostic mammographies, there do not need to be signs, 
symptoms, or history of breast disease in order for the exam to be covered. You can find this rule in the 
Medicare Benefit Policy Manual, Chapter 15, Section 280.3. 
 
The rules also say that a diagnostic mammography is a radiological mammogram and is a covered diagnostic 
test under the following conditions: 
 
A patient has distinct signs and symptoms for which a mammogram is indicated; 
A patient has a history of breast cancer; or 
A patient is asymptomatic, but based on the patient's history and other factors the physician considers 
significant, the physician's judgment is that a mammogram is appropriate. 
 
The following HCPCS codes are used to bill for mammography services: 
77065-Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral 
77066-Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral 
77067-Screening mammography, bilateral (2-view study of each breast), including computer-aided detection 
(CAD) when performed. 
You can find these rules in the Medicare Claims Processing Manual, Chapter 18, Sections 20 and 20.2. 
 
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. The Plan 
contract states that one screening mammogram every 12 months for women age 40 and older. However, 
diagnostic mammograms are subject to cost sharing as described under Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies. The screening mammography annual benefit is not available for members 
who have signs or symptoms of breast cancer. You can find this information on page 4-11 of the Plan's 2020 
EOC.