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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 Medicare has determined for which surgical services an assistant surgeon is medically necessary. This information can be found in the Medicare Fee Schedule Database. If the database contains an 
assistant at surgery indicator of 1 for the surgical procedure in question, Medicare has determined that an 
assistant is not medically necessary. Assistant surgeons will not be paid for these procedures. You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing 
Manual, Chapter 12, Section 40.8. 
 
The rules state that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the 
left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for 
both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified 
side. 
 
When a patient has a bilateral condition and each side is treated during separate encounters, assign the 
"bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side. 
For the second encounter for treatment after one side has previously been treated and the condition no longer 
exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., 
cataract surgery performed on each eye in separate encounters). The bilateral code would not be assigned for 
the subsequent encounter, as the patient no longer has the condition in the previously-treated site. If the 
treatment on the first side did not completely resolve the condition, then the bilateral code would still be 
appropriate. 
 
You can find this rule in the ICD-10-CM Official Guidelines for Coding and Reporting, FY 2023. 
 
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.