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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 Covered ambulatory surgery center (ASC) services are those surgical procedures that 
are identified by CMS on a listing that is updated at least annually. Some surgical procedures are covered by 
Medicare but are not on the list of ASC covered surgical procedures. For surgical procedures that are 
performed but not covered in ASCs, the related professional services may be billed by the rendering provider 
as Part B services and the beneficiary is liable for the facility charges, which are non-covered by Medicare. 
A single payment is made to an ASC for facility services furnished by the ASC in connection with a covered 
surgical procedure. Additional payments may be made to the ASC for covered ancillary services, specifically 
brachytherapy sources, certain implantable devices with pass-through status under the OPPS, corneal tissue 
acquisition, drugs and biologicals for which separate payment is allowed under the OPPS, radiology services 
for which separate payment is allowed under the OPPS, and certain other integral services not included in the 
primary procedure payment. To be covered ancillary services for which separate payment is made, these items 
and services must be provided integral to covered surgical procedures, that is, immediately before, during, or 
immediately after the covered surgical procedure. Section 20 - List of Covered Ambulatory Surgical Center 
Procedures: The complete lists of ASC covered surgical procedures and ASC covered ancillary services, the 
applicable payment indicators, payment rates for each covered surgical procedure and ancillary service before 
adjustments for regional wage variations. You can find this guidance in the Medicare Claims Processing 
Manual Chapter 14 - Ambulatory Surgical Centers, 10.2- Ambulatory Surgical Center Services on ASC List, 
10.3 - Services Furnished in ASCs Which Are Not ASC Facility Services or Covered Ancillary Services and 20 
- List of Covered Ambulatory Surgical Center Procedures. Medicare guidance says These files contain the 
procedure codes which may be performed in an ASC under the Medicare program as well as the ASC payment 
group assigned to each of the procedure codes. The ASC payment group determines the amount that Medicare 
pays for facility services furnished in connection with a covered procedure. For 2000 - 2006 files, go to the 
ASC Payment Rates Archive page (see the Left column). You can find this guidance in the CMS.gov, 
Ambulatory Surgical Center (ASC) Payment. 
 
Medicare guidance says Addendum AA --Final ASC Covered Surgical Procedures for CY2022 (Including 
Surgical Procedures for Which Payment is Packaged) - Procedure code 64999 not found. You can find this 
guidance in the ASC Payment Rates- Addenda (CY 2022 April ASC Addenda Addendum AA). 
 Medicare guidance says Addendum AA - a list of covered surgical procedures under the revised ASC payment 
system, including Category I and Category III CPT and Level II HCPCS codes. Included are surgical 
procedures that receive packaged payment through the payment for covered surgical procedures, as well as 
those that are paid separately. Payment indicators (defined in Addendum DD1) designate each procedure's 
payment status. You can find this guidance in the ASC Addenda Table of Contents. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.