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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 Medicare Advantage Organizations (MAOs) are responsible for payment of claims related to 
enrollees? participation in both Category A and B IDE studies that are covered by the MAC with jurisdiction 
over the MA plan?s service area. The MAO is responsible for payment of routine care items and services in 
CMS-approved Category A and Category B IDE studies. The MAO is also responsible for coverage of CMS-
approved Category B devices themselves. You can find this information at Medicare Managed Care Manual 
Chapter 4, Section 10.7.2 ? Payment for Investigational Device Exemption (IDE) Studies. 
 
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 health 
plan contract states, "once you join a Medicare-approved clinical research study, you are covered for routine 
items and services you receive as part of the study, including: ?Room and board for a hospital stay that 
Medicare would pay for even if you weren't in a study. ?An operation or other medical procedure if it is part of 
the research study. ?Treatment of side effects and complications of the new care. Original Medicare pays most 
of the cost of the covered services you receive as part of the study. After Medicare has paid its share of the cost 
for these services, our plan will also pay for part of the costs: ?We will pay the difference between the cost-
sharing in Original Medicare and your cost-sharing as a member of our plan. This means you will pay the same 
amount for the services you receive as part of the study as you would if you received these services from our 
plan. Here's an example of how the cost-sharing works: Let's say that you have a lab test that costs $100 as part 
of the research study. Let's also say that your share of the costs for this test is $20 under Original Medicare, but 
the test would be $10 under our plan's benefits. In this case, Original Medicare would pay $80 for the test and 
we would pay another $10. This means that you would pay $10, which is the same amount you would pay 
under our plan's benefits. ?In order for us to pay for our share of the costs, you will need to submit a request for 
payment. With your request, you will need to send us a copy of your Medicare Summary Notices or other 
documentation that shows what services you received as part of the study and how much you owe. Please see 
Chapter 7 for more information about submitting requests for payment. When you are part of a clinical research 
study, neither Medicare nor our plan will pay for any of the following: Generally, Medicare will not pay for the 
new item or service that the study is testing, unless Medicare would cover the item or service even if you were 
not in a study. ?Items and services the study gives you or any participant for free. ?Items or services provided 
only to collect data, and not used in your direct health care. For example, Medicare would not pay for monthly 
CT scans done as part of the study if your medical condition would normally require only one CT scan." You 
can find this information in Chapter 3 on page 47 of the plan's 2020 Evidence of Coverage.