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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 an "order" is a communication from the treating physician/practitioner requesting that a 
diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test 
for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined 
by the treating physician/practitioner. An order may be delivered via the following forms of communication: 
- A written document signed by the treating physician/practitioner, which is hand- delivered, mailed, or 
faxed to the testing facility; NOTE: No signature is required on orders for clinical diagnostic tests paid 
on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician 
pathology services;. 
- A telephone call by the treating physician/practitioner or his/her office to the testing facility; and 
- An electronic mail by the treating physician/practitioner or his/her office to the testing facility. 
 
If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the 
testing facility must document the telephone call in their respective copies of the beneficiary's medical records. 
While a physician order is not required to be signed, the physician must clearly document, in the medical 
record, his or her intent that the test be performed. 
 
A "treating physician" is a physician, as defined in Section 1861(r) of the Social Security Act (the Act), who 
furnishes a consultation or treats a beneficiary for a specific medical problem, and who uses the results of a 
diagnostic test in the management of the beneficiary's specific medical problem. 
 
A radiologist performing a therapeutic interventional procedure is considered a treating physician. A 
radiologist performing a diagnostic interventional or diagnostic procedure is not considered a treating 
physician. 
 
A "treating practitioner" is a nurse practitioner, clinical nurse specialist, or physician assistant, as defined in 
1861(s)(2)(K) of the Act, who furnishes, pursuant to State law, a consultation or treats a beneficiary for a specific medical problem, and who uses the result of a diagnostic test in the management of the beneficiary's 
specific medical problem. You can find this information in the Centers for Medicare & Medicaid Service, 
Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.6.1. 
 
The rules say that the term physician means: 
- a doctor of medicine or osteopathy, 
- a doctor of dental surgery or of dental medicine, 
- a doctor of podiatric medicine, 
- a doctor of optometry, 
- a chiropractor - but only with respect to treatment by means of manual manipulation of the spine (to 
correct a subluxation). 
You can find this information in the Social Security Act, Section 1861(r). 
 
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.