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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 payment for inpatient hospital services is made on the basis of a DRG (diagnosis related group). 
Hospitals must provide proper information about the patient (i.e., age, sex, discharge status, principal and 
secondary diagnoses, and procedures) in order for the correct DRG to be assigned. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 3, Section 20.2.1. 
 
The rules say that the circumstances of inpatient admission always govern the selection of principal diagnosis. 
The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition 
established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for 
care. For reporting purposes, the definition for other diagnoses is interpreted as additional conditions that 
affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; 
or extended length of hospital stay; or increased nursing care and/or monitoring. The UHDDS item #11-b 
defines Other Diagnoses as all conditions that coexist at the time of admission, that develop subsequently, or 
that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which 
have no bearing on the current hospital stay are to be excluded. You can find this information in the 
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Official Guidelines 
for Coding and Reporting, Sections II and III. 
 
The rules say that for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiarys medical 
documentation and confirm that Medicare coverage criteria have been met. You can find this rule in the 
Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.1. 
 
The rules state that the following medical items, supplies, and services furnished to inpatients are covered 
under Part A. Consequently, they are covered by the prospective payment rate or reimbursed as reasonable costs under Part 
A to hospitals excluded from prospective payment system (PPS). 
-Laboratory services (excluding anatomic pathology services and certain clinical pathology services); 
-Pacemakers and other prosthetic devices including lenses, and artificial limbs, knees, and hips; 
-Radiology services including computed tomography (CT) scans furnished to inpatients by a physician's office, 
other hospital, or radiology clinic; 
-Total parenteral nutrition (TPN) services; and 
-Transportation, including transportation by ambulance, to and from another hospital or freestanding facility to 
receive specialized diagnostic or therapeutic services not available at the facility where the patient is an 
inpatient. 
The hospital must include the cost of these services in the appropriate ancillary service cost center, i.e., in the 
cost of the diagnostic or therapeutic service. It must not show them separately under revenue code 0540. 
You can find this rule in the Centers for Medicare & Medicaid Service, Medicare Claims Processing Manual, 
Chapter 3, Section 10.4.A. 
 
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.