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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 claims processing contractors will be required to sum all units of service (UOS) for the code 
for the same date of service, for the same Health Insurance Claim Number (HICN), and for the same provider 
on: 
 
1. All claim lines of the current claim 
2. Paid claim lines of prior finalized claims. 
 
The number should be compared to the Medically Unlikely Edits (MUE) value. If the sum of all UOS for the 
same date of service on all specified claims exceeds the MUE value for the code, contractors shall deny all 
claim lines for the code for the same date of service on the current claim. 
 
You can find this rule in the Centers for Medicare & Medicaid Services (CMS) Manual System, Pub 100-20 
One Time Notification, Transmittal 1421, Change Request 8853, Effective August 15, 2014. 
 
The rules say that Medically Unlikely Edits (MUEs) for HCPCS codes with an MAI of 3 are per day edits 
based on clinical benchmarks. MUEs assigned an MAI of 3 are based on criteria (e.g., nature of service, 
prescribing information) combined with data such that it would be possible but medically highly unlikely that 
higher values would represent correctly reported medically necessary services. If contractors have evidence 
(e.g., medical review) that UOS in excess of the MUE value were actually provided, were correctly coded and 
were medically necessary, the contractor may bypass the MUE for a HCPCS code with an MAI of 3 during 
claim processing, reopening, or redetermination, or in response to effectuation instructions from a 
reconsideration or higher-level appeal. 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 the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. 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 20.9. 
 
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.