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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. 
 
Medicare guidance says In this Manual many policies are described utilizing the term physician. Unless 
indicated differently the usage of this term does not restrict the policies to physicians only but applies to all 
practitioners, hospitals, providers, or suppliers eligible to bill the relevant HCPCS/CPT codes pursuant to 
applicable portions of the Social Security Act (SSA) of 1965, the Code of Federal Regulations (CFR), and 
Medicare rules. Providers reporting services under Medicares hospital outpatient prospective payment system 
(OPPS) shall report all services in accordance with appropriate Medicare Internet-only Manual (IOM) 
instructions. Procedures shall be reported with the most comprehensive CPT code that describes the services 
performed. You can find the guidance in the National Correct Coding Initiative Policy Manual Chapter I 
General Correct Coding Policies. Medicare guidance says, the 'integrated' Outpatient Code Editor (I/OCE) 
program processes claims for all outpatient institutional providers including hospitals that are subject to the 
Outpatient Prospective Payment System (OPPS) as well as hospitals that are NOT (Non-OPPS). Claim will be 
identified as 'OPPS' or 'Non-OPPS' by passing a flag to the OCE in the claim record, 1=OPPS, 2=Non-OPPS; a 
blank, zero, or any other value is defaulted to 1. The OCE not only identifies individual errors but also 
indicates what actions should be taken and the reasons why these actions are necessary. In order to 
accommodate this functionality, the OCE is structured to return lists of edit numbers. This structure facilitates 
the linkage between the actions being taken, the reasons for the actions and the information on the claim (e.g., a 
specific diagnosis) that caused the action. You can find the guidance in the CMS.gov Outpatient Code Editor 
(OCE). 
 
Medicare guidance says, as specified in the introduction to the IOCE, one of the three major functions provided 
by the IOCE is the application of edit(s) to identify errors. Each edit is unique, as it directly links the reason the 
edit is returned, any related information at the line or claim level, and the action required indicated by the edit 
disposition. For example, an edit can cause a line-item rejection or return the claim to the provider. It is 
possible for a claim to have one or more edits in all 6 dispositions. 6.1.1 Edit Disposition Table Disposition  
Claim Return to Provider, Description  There are one or more edits present that cause the whole claim to be 
returned to the provider. A claim returned to the provider means that the provider can resubmit the claim once 
the problems are corrected. 6.2 Edit Descriptions and Reason for Edit Generation Table Edit 62, Edit Description  Code not recognized by OPPS; alternate code for same service may be available, Reason for Edit 
Generation  The procedure code has a Not recognized by Medicare for OPPS indicator. Services with a 
status indicator of B always return edit 62, Disposition  RTP 7.1.2 APC Return Buffer Table Name  Status 
Indicator (SI), Description  B Non-allowed item or service for OPPS. You can find the guidance in the 
CMS.gov, OCE Quarterly Release Files, Integrated OCE (IOCE) CMS Specifications V22.3 R1 Effective July 
01, 2021, Section 6 Edit Application within the IOCE, Section 6.1 Introduction to Edits, Section 6.1.1 Edit 
Disposition Table, Section 6.2 Edit Descriptions and Reason for Edit Generation Table and Section 7.1.2 APC 
Return Buffer Table Medicare guidance says Section 1833(t) of the Social Security Act (the Act) as amended 
by Section 4533 of the Balanced Budget Act (BBA) of 1997, authorizes CMS to implement a Medicare PPS 
for: Hospital outpatient services, including partial hospitalization services; 10.1.1  Payment Status Indicators 
An OPPS payment status indicator is assigned to every HCPCS code. The status indicator identifies whether 
the service described by the HCPCS code is paid under the OPPS and if so, whether payment is made 
separately or packaged. The status indicator may also provide additional information about how the code is 
paid under the OPPS or under another payment system or fee schedule. For example, services with status 
indicator A are paid under a fee schedule or payment system other than the OPPS. Services with status 
indicator N are paid under the OPPS, but their payment is packaged into payment for a separately paid service. 
Services with status indicator T are paid separately under OPPS but a multiple procedure payment reduction 
applies when two or more services with a status indicator of T are billed on the same date of service. The full 
list of status indicators and their definitions is published in Addendum D1 of the OPPS/ASC proposed and final 
rules each year. The status indicator for each HCPCS code is shown in OPPS Addendum B. 40.1  Integrated 
OCE (July 2007 and Later). Effective for claims with dates of service July 1, 2007, and after, the non-
Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be integrated into the 
OPPS OCE. This integration will result in the routing of all institutional outpatient claims, including non-OPPS 
hospital claims, through a single integrated OCE eliminating the need to update two separate OCE software 
packages on a quarterly basis. 120.1  Bill Types Subject to OPPS The following bill types are subject to 
OPPS: All outpatient hospital Part B bills (bill types 12X, 13X with condition code 41 14X and 13X without 
condition code 41) with the exception of bills from hospitals in Maryland, Indian Health Service, CAHs, 
hospitals located in Saipan, American Samoa, the Virgin Islands and Guam; and hospitals that provide Part B 
only services to their inpatients. You can find the guidance in the Medicare Claims Processing Manual, Chapter 
4  Part B Hospital (Including Inpatient Hospital Part B and OPPS), Section 10.1  Background, Section 10.1.1 
 Payment Status Indicators, Section 40.1  Integrated OCE (July 2007 and Later) and Section 120.1  Bill 
Types Subject to OPPS Medicare guidance says Addendum B.  HCPCS code 77049 MRI breast c-+ w/cad 
bi, Status Indicator  B. You can find the guidance says CMS.gov, Hospital Outpatient PPS, Addendum A and 
Addendum B Updates, 2021 October Web Addendum B. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.