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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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that Some hospitals also provide services on an outpatient basis, either individually or as part of a 
day hospitalization program, for treatment of alcoholism. These services may include, for example, drug 
therapy, psychotherapy, and patient education and may be furnished by physicians, psychologists, nurses, and 
alcoholism counselors to individuals who have been discharged from an inpatient hospital stay for treatment of 
alcoholism and require continued treatment or to individuals from the community who require treatment but do 
not require the inpatient hospital setting. Coverage is available for both diagnostic and therapeutic services 
furnished for the treatment of alcoholism by the hospital to outpatients subject to the same rules applicable to 
outpatient hospital services in general. While there is no coverage for day hospitalization programs, per se, 
individual services which meet the requirements in the Medicare Benefit Policy Manual, Chapter 6, Section 20 
may be covered. All services must be reasonable and necessary for diagnosis or treatment of the patient's 
condition. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Medicare National Coverage Determination for Outpatient Hospital Services for Treatment of Alcoholism, 
130.2. 
 
The rules say that coverage is available for alcoholism or drug abuse treatment services (such as drug therapy, 
psychotherapy, and patient education) that are provided incident to a physician's professional service in a 
freestanding clinic to patients who, for example, have been discharged from an inpatient hospital stay for the 
treatment of alcoholism or drug abuse or to individuals who are not in the acute stages of alcoholism or drug 
abuse but require treatment. The coverage available for these services is subject to the same rules generally 
applicable to the coverage of clinic services.  Of course, the services also must be reasonable and necessary for 
the diagnosis or treatment of the individual's alcoholism or drug abuse. The Part B psychiatric limitation would 
apply to alcoholism or drug abuse treatment services furnished by physicians to individuals who are not 
hospital inpatients. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Medicare National Coverage Determination for Treatment of Alcoholism and Drug Abuse in a 
Freestanding Clinic, 130.5. 
 
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.