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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 Centers for Medicare and Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied. 
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. Codes with an MAI of 3 are based on criteria combined with data such that it would be 
possible, but medically unlikely, that higher values would represent correctly reported medically necessary 
services. To be paid, there must be evidence (e.g., medical review) that the excess units were actually provided, 
were correctly coded, and were medically necessary. 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(V). 
 The rules say that debridement of tissue in the surgical field of another musculoskeletal procedure is not 
separately reportable. For example, debridement of muscle and/or bone (CPT codes 11043-11044, 11046-
11047) associated with excision of a tumor of bone is not separately reportable. Similarly, debridement of 
tissue (e.g., CPT codes 11042, 11045, 11720-11721, 97597, 97598) superficial to, but in the surgical field, of a 
musculoskeletal procedure is not separately reportable. However, debridement of tissue at the site of an open 
fracture or dislocation may be reported separately with CPT codes 11010-11012. 
 
If the code descriptor of a HCPCS/CPT code includes the phrase separate procedure, the procedure is subject 
to NCCI PTP edits based on this designation. CMS does not allow separate reporting of a procedure designated 
as a separate procedure when it is performed at the same patient encounter as another procedure in an 
anatomically related area through the same skin incision, orifice, or surgical approach. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding 
Initiative Policy Manual for Medicare Services, Chapter IV, Section I(11 and 26). 
 
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.