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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 "The civil False Claims Act protects the Federal Government from being overcharged or sold substandard goods or services. The civil FCA imposes civil liability on any person who knowingly submits, or causes the submission of, a false or fraudulent claim to the Federal Government. The terms "knowing" and"knowingly" mean a person has actual knowledge of the information or acts in deliberate ignorance or reckless disregard of the truth or falsity of the information related to the claim. No proof of specific intent to defraud is required to violate the civil FCA. An example may be a physician who knowingly submits claims to Medicare for medical services not provided. Civil penaltiesfor violating the FCA may include fines of up to three times the amount of damages sustained by the Government as a result of the false claims, plus up to $22,927 (in 2019) per false claim filed. Additionally, under various Federal criminal statutes, individuals or entities may face criminal penalties for submitting false claims, including fines, imprisonment, or both. Also, "theCriminal Health Care Fraud Statute prohibits knowingly and willfully executing, or attempting to execute, a scheme or lie in connection with the delivery of, or payment for, health care benefits, items, or services to either; defraud any health care benefit program, or obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the control of, any health care benefit program. Penalties for violating the Criminal Health Care Fraud Statute may include fines, imprisonment, or both. "Section 1877 of the Social Security Act (the Act) (42 U.S.C. 1395nn), also known as the physician self-referral law and commonly referred to as the "Stark Law"; prohibits a physician from making referrals for certain designated health services (DHS) payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship (ownership, investment, or compensation), unless an exception applies, prohibits the entity from presenting or causing to be presented claims to Medicare (or billing another individual, entity, or third party payer) for those referred services, and establishes a number of specific exceptions and grants the Secretary the authority to create regulatory exceptions for financial relationships that do not pose a risk of program or patient abuse. The following items or services are DHS; Clinical laboratory services, Physical therapy services, Occupational therapy services, Outpatient speech-language pathology services, Radiology and certain other imaging services, Radiation therapy services and supplies, Durable medical equipment and supplies, Parenteral and enteral nutrients, equipment, and supplies, Prosthetics, orthotics, and prosthetic devices and supplies, Home health services, Outpatient prescription drugs and Inpatient and outpatient hospital services." "On September 23, 2010, we published the Medicare self-referral disclosure protocol ("SRDP") pursuant to Section 6409(a) of the Patient Protection and Affordable Care Act (ACA). The SRDP sets forth a process to enable providers of services and suppliers to self-disclose actual or potential violations of the physician self-referral statute. Additionally, Section 6409(b) of the ACA, gives the Secretary of HHS the authority to reduce the amount due and owing for violations of Section 1877." "Abuse includes actions that may, directly or indirectly, result in: unnecessary costs to the Medicare Program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services whenthere is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Abuse cannot be differentiated categorically from fraud, because the distinction between "fraud" and"abuse" depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other factors.". You can find this guidance in the MLN Matters; ICN MLN4649244 February 2019 -Medicare Fraud & Abuse: Prevent, Detect, and Report, and ICN 905645 November 2017 -Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians. https://www.gpo.gov/fdsys/pkg/USCODE-2016-title31/pdf/USCODE-2016-title31-subtitleIII-chap37-subchapIII.pdf https://www.cms.gov/Medicare/Fraud-and-abuse/PhysicianSelfReferral/index.html https://www.gpo.gov/fdsys/pkg/USCODE-2016-title42/pdf/USCODE-2016-title42-chap7-subchapXVIII-partE-sec1395nn.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c21.pdf Medicare Managed Care Manual Chapter 21 -Compliance Program Guideline