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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 health plans, physicians, hospitals, and other health care providers must comply with the 
Official International Classification of Disease, 10th Edition, Clinical Modification (ICD-10-CM) Coding 
Guidelines. 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 10. 
 
The rules also say that certain conditions have both an underlying etiology and multiple body system 
manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention 
that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 
Wherever such a combination exists, there is a use additional code note at the etiology code, and a code 
first note at the manifestation code. These instructional notes indicate the proper sequencing order of the 
codes, etiology followed by manifestation. In most cases the manifestation codes will have in the code title, in 
diseases classified elsewhere. Codes with this title are a component of the etiology/ manifestation convention. 
The code title indicates that it is a manifestation code. You can find this information in the ICD-10-CM Official 
Guidelines for Coding and Reporting, Section I, Conventions, general coding guidelines and chapter specific 
guidelines. 
 
The rules say that the appropriate code(s) from A00.0 through T88.9, Z00-Z99 and U00-U85 must be used to 
identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit. 
 
The rules say that codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for 
reporting purposes when a diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-
10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified (codes 
R00-R99) contain many, but not all codes for symptoms. 
 
The rules say that for patients receiving diagnostic services only during an encounter/visit, sequence first the 
diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., 
chronic conditions) may be sequenced as additional diagnoses. 
 
For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated 
diagnosis, assign Z01.89, Encounter for other specified special examinations. If routine testing is performed 
during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both 
the Z code and the code describing the reason for the non-routine test. 
 
For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is 
available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the 
interpretation. Do not code related signs and symptoms as additional diagnoses. 
 
You can find these rules in the ICD-10-CM Official Guidelines for Coding and Reporting, Section IV, 
Diagnostic Coding and Reporting Guidelines for Outpatient Services. 
 
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.