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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 
 
A/B MACs (B) may not pay for the technical component (TC) of radiology services furnished to hospital 
patients. Payment for physicians radiological services to the hospital, e.g., administrative or supervisory 
services, and for provider services needed to produce the radiology service, is made by the AB MAC (A) 
to the hospital as a provider service. Radiology and other diagnostic services furnished to hospital outpatients 
are paid under the Outpatient Prospective Payment System (OPPS) to the hospital. Medicare Claims Processing 
Manual Chapter 26 - Completing and Processing Form CMS -1500 Data Set, 10.5 - Place of Service Codes 
(POS) and Definitions: *A portion of a hospital where emergency diagnosis and treatment of illness or injury is 
provided. Medicare Claims Processing Manual Chapter 23  Fee Schedule Administration and Coding 
Requirements 30  Services Paid Under the Medicare Physicians Fee Schedule Following is a general 
description of services paid under the Medicare Physicians Fee Schedule (MPFS). A. Physicians Services 
Effective with services furnished on or after January 1, 1992, A/B MACs (B) pay for physicians services 
based on the MPFS. The Medicare allowed charge for such physicians services is the lower of the actual 
charge or the fee schedule amount. The Medicare payment is 80 percent of the allowed charge after the 
deductible is met for most services paid based on the fee schedule. Exceptions to the rule, e.g., services for 
which deductible is not applicable, are specifically identified for the service where the exception applies. The 
Physicians Fee Schedule is used when paying for the following physicians services. Services covered incident 
to physicians services other than certain drugs covered as incident to services. 30.2  MPFSDB Record 
Layout. The CMS MPFSDB includes the total fee schedule amount, related. component parts, and payment 
policy indicators. The record layout is provided in the Addendum below. 50.6  Physician Fee Schedule 
Payment Policy Indicator File Record Layout Professional Component (PC)/Technical Component (TC) Indicator 5 = Incident to Codes: This indicator identifies codes that describe services covered incident to a 
physicians service when they are provided by auxiliary personnel employed by the physician and working 
under his or her direct supervision. Payment may not be made by carriers for these services when they are 
provided to hospital inpatients or patients in a hospital outpatient department. Modifiers 26 and TC cannot be 
used with these codes. CMS.gov, Physician Fee Schedule (PFS) Relative Value Files 2020 National Physician 
Fee Schedule Relative Value File July Release HCPCS 69209, PCTC Indicator = 5. You can find this 
information in the Medicare Claims Processing Manual Chapter 13  Radiology Services and Other Diagnostic 
Procedures 20.2.1  Hospital and Skilled Nursing Facility (SNF) Patients. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.