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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 state that when completing the 1500 claim form, providers must enter the correct Place of Service 
(POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. If the 
physician bills for lab services performed in his/her office, the POS code for "Office" is shown. If the physician 
bills for a lab test furnished by another physician, who maintains a lab in his/her office, the code for "Other" is shown. If the physician bills for a lab service furnished by an independent lab, the code for "Independent 
Laboratory" is used. Items 21 and 22 on the Form CMS-1500 must be completed for all laboratory work 
performed outside a physician's office. If an independent lab bills, the place where the sample was taken is 
shown. An independent laboratory taking a sample in its laboratory shows "81" as place of service. If an 
independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, it uses the 
code for the inpatient (POS code 21), off campus-outpatient hospital (POS code 19), or on campus-outpatient 
hospital (POS code 22), respectively. You can find this rule at Medicare Claims Processing Manual Chapter 26 
Section 10.6. 
 
The rules say 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 beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can find this rule at 42 CFR 
Section 424.5. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.