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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 critical care visits are sometimes needed during the global period of a procedure, whether pre-
operatively, on the same day, or during the post-operative period. In some cases, preoperative and 
postoperative critical care visits are included in procedure codes that have a global surgical period. 
In those cases where a critical care visit is unrelated to the procedure with a global surgical period, critical care 
visits may be paid separately in addition to the procedure. Preoperative and/or postoperative critical care may 
be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care) and 
requires the full attention of the physician, and the critical care is above and beyond and unrelated to the 
specific anatomic injury or general surgical procedure performed (for example, trauma, burn cases).  
 When the critical care service is unrelated to the procedure, append the modifier -FT ((unrelated evaluation and 
management (E/M) visit on the same day as another E/M visit or during a global procedure (preoperative, 
postoperative period, or on the same day as the procedure, as applicable). (Report when an E/M visit is 
furnished within the global period but is unrelated, or when one or more additional E/M visits furnished on the 
same day are unrelated.)) to the critical care CPT code(s). You can find this rule in the Centers for Medicare 
and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, 
Chapter 12, Section 30.6.12.7. 
 
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.