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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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that A/B MACs (B) may not pay for the technical component (TC) of radiology services 
furnished to hospital patients. Payment for physicians radiological services to the hospital, e.g., administrative 
or supervisory services, and for provider services needed to produce the radiology service, is made by the A/B 
MAC (A) to the hospital as a provider service. A/B MACs (A) include the TC of radiology services for hospital inpatients, except Critical Access Hospitals (CAHs), in the prospective payment system (PPS) payment to 
hospitals. Hospital bundling rules exclude payment to suppliers of the TC of a radiology service for 
beneficiaries in a hospital inpatient stay. The TC of radiology and other diagnostic services furnished to 
hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the hospital. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual Publication 100-04, Medicare Claims Processing Manual Chapter 13, Section 20.2.1. 
 
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.