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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 Medicare covers the routine costs of qualifying clinical trials, as such costs are defined 
below, as well as reasonable and necessary items and services used to diagnose and treat complications arising 
from participation in all clinical trials. All other Medicare rules apply. 
 
Routine costs of a clinical trial include all items and services that are otherwise generally available to Medicare 
beneficiaries (i.e., there exists a benefit category, it is not statutorily excluded, and there is not a national non-
coverage decision) that are provided in either the experimental or the control arms of a clinical trial except: 
 
    The investigational item or service, itself unless otherwise covered outside of the clinical trial; 
    Items and services provided solely to satisfy data collection and analysis needs and that are not used in the 
direct clinical management of the patient (e.g., monthly CT scans for a condition usually requiring only a single 
scan); and 
    Items and services customarily provided by the research sponsors free-of-charge for any enrollee in the trial. 
 
Routine costs in clinical trials include: 
    Items or services that are typically provided absent a clinical trial (e.g., conventional care); 
    Items or services required solely for the provision of the investigational item or service (e.g., administration 
of a noncovered chemotherapeutic agent), the clinically appropriate monitoring of the effects of the item or 
service, or the prevention of complications; and 
    Items or services needed for reasonable and necessary care arising from the provision of an investigational 
item or service in particular, for the diagnosis or treatment of complications. 
 
Any clinical trial receiving Medicare coverage of routine costs must meet the following three requirements: 
    The subject or purpose of the trial must be the evaluation of an item or service that falls within a Medicare 
benefit category (e.g., physicians' service, durable medical equipment, diagnostic test) and is not statutorily 
excluded from coverage (e.g., cosmetic surgery, hearing aids). 
    The trial must not be designed exclusively to test toxicity or disease pathophysiology. It must have 
therapeutic intent. 
    Trials of therapeutic interventions must enroll patients with diagnosed disease rather than healthy volunteers. 
Trials of diagnostic interventions may enroll healthy patients in order to have a proper control group. 
 
The three requirements above are insufficient by themselves to qualify a clinical trial for Medicare coverage of 
routine costs. Clinical trials also should have the following desirable characteristics; however, some trials, as described below, are presumed to meet these characteristics and are automatically qualified to receive Medicare 
coverage: 
 
    The principal purpose of the trial is to test whether the intervention potentially improves the participants' 
health outcomes; 
    The trial is well-supported by available scientific and medical information or it is intended to clarify or 
establish the health outcomes of interventions already in common clinical use; 
    The trial does not unjustifiably duplicate existing studies; 
    The trial design is appropriate to answer the research question being asked in the trial; 
    The trial is sponsored by a credible organization or individual capable of executing the proposed trial 
successfully; 
    The trial is in compliance with Federal regulations relating to the protection of human subjects; and 
    All aspects of the trial are conducted according to the appropriate standards of scientific integrity. 
 
The CMS, through the NCD process, through an individualized assessment of benefits, risks, and research 
potential, may determine that certain items and services for which there is some evidence of significant medical 
benefit, but for which there is insufficient evidence to support a reasonable and necessary determination, are 
only reasonable and necessary when provided in a clinical trial that meets the requirements defined in that 
NCD. You can find this rule in the National Coverage Determination (NCD) Routine Costs in Clinical Trials 
310.1. 
 
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.