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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. 
 
Effective January 1, 2015, the Centers for Medicare and Medicaid Services (CMS) has established four new 
Healthcare Common Procedure Coding System (HCPCS) modifiers (referred collectively as the -X{EPSU} 
Modifiers) to define specific subsets of the -59 modifier. CMS will continue to recognize the -59 modifier, but 
notes that -59 should not be used when a more descriptive modifier is available. CMS may selectively require a 
more specific -X{EPSU} modifier for billing certain codes at high risk for incorrect billing. Contractors will 
apply or bypass edits to lines containing a =X{EPSU} modifier in the same manner as the edits would apply to 
a line containing a -59 modifier. 
 
XE  Separate Encounter, A service that is distinct because it occurred during a separate encounter. This 
modifier shall only be used to describe separate encounters on the same date of service.  
 
XS  Separate Structure, A service that is distinct because it was performed on a separate organ/structure  
 
XP  Separate Practitioner, A service that is distinct because it was performed by a different practitioner  
 
XU  Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual 
components of the main service  
 
You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding 
Initiative Policy Manual for Medicare Services, Chapter X(E). 
 
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.