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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 professional component of a diagnostic procedure furnished to a beneficiary in a hospital 
includes an interpretation and written report for inclusion in the beneficiarys medical record maintained by the 
hospital. 
 
The rules say that A/B MACs (B) generally distinguish between an interpretation and report of an x-ray or an 
EKG procedure and a review of the procedure. A professional component billing based on a review of the 
findings of these procedures, without a complete, written report similar to that which would be prepared by a 
specialist in the field, does not meet the conditions for separate payment of the service. This is because the 
review is already included in the emergency department evaluation and management (E/M) payment. 
 
The rules also say that Generally, A/B MACs (B) must pay for only one interpretation of an EKG or x-ray 
procedure furnished to an emergency room patient. They pay for a second interpretation (which may be 
identified through the use of modifier -77) only under unusual circumstances (for which documentation is 
provided) such as a questionable finding for which the physician performing the initial interpretation believes 
another physicians expertise is needed or a changed diagnosis resulting from a second interpretation of the 
results of the procedure. 
 
When A/B MACs (B) receive only one claim for an interpretation, they must presume that the one service 
billed was a service to the individual beneficiary rather than a quality control measure and pay the claim if it 
otherwise meets any applicable reasonable and necessary test. 
 
When A/B MACs (B) receive multiple claims for the same interpretation, they must generally pay for the first 
bill received. A/B MACs (B) must pay for the interpretation and report that directly contributed to the 
diagnosis and treatment of the individual patient. Consideration is not given to physician specialty as the primary factor in deciding which interpretation and report to pay regardless of when the service is performed. 
Consideration is not given to designation as the hospitals official interpretation as a factor in determining 
which claim to pay. A/B MACs (B) pay for the 
interpretation billed by the cardiologist or radiologist if the interpretation of the procedure is performed at the 
same time as the diagnosis and treatment of the beneficiary.  
 
If the first claim received is from a radiologist, A/B MACs (B) generally pay the claim because they would not 
know in advance that a second claim would be forthcoming. When A/B MACs (B) receive the claim from the 
emergency room (ER) physician and can identify that the two claims are for the same interpretation, they must 
determine whether the claim from the ER physician was the interpretation that contributed to the diagnosis and 
treatment of the patient and, if so, they pay that claim. In such cases, A/B MACs (B) must determine that the 
radiologists claim was actually quality control and institute recovery action. 
 
You can find these rules in the Medicare Claims Processing Manual, Chapter 13, Section 100.1. 
 
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.