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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 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. 
 
The rules say that Modifier 25: The CPT Manual defines modifier 25 as a Significant, Separately 
Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care 
Professional on the Same Day of the Procedure or Other Service. Modifier 25 may be appended to an 
evaluation and management (E&M) CPT code to indicate that the E&M service is significant and separately 
identifiable from other services reported on the same date of service. The E&M service may be related to the 
same or different diagnosis as the other procedure(s). Modifier 25 may be appended to E&M services reported 
with minor surgical procedures (with global periods of 000 or 010 days) or procedures not covered by Global 
Surgery Rules (with a global indicator of XXX). Since minor surgical procedures and XXX procedures include 
pre-procedure, intra-procedure, and post-procedure work inherent in the procedure, the provider/supplier shall not report an E&M service for this work. Furthermore, Medicare Global Surgery Rules prevent the reporting of 
a separate E&M service for the work associated with the decision to perform a minor surgical procedure 
regardless of whether the patient is a new or established patient. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, National Correct Coding Initiative Policy Manual, 
Chapter 1, Section E(d). 
 
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.