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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 the Centers for Medicare & Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied. 
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code 
on separate lines of the claim. MUEs for codes with an MAI of 2 are absolute date of service edits. These are 
per day edits based on policy. MUEs for codes with an MAI of 3 are per day edits based on clinical 
benchmarks. Codes with an MAI of 3 are based on criteria combined with data such that it would be 
possible, but medically unlikely, that higher values would represent correctly reported medically necessary 
services. To be paid, there must be evidence (e.g., medical review) that the excess units were actually provided, 
were correctly coded, and were medically necessary. 
 
You can find this rule in the Centers for Medicare & Medicaid Services, Medicare National Correct Coding 
Initiative Policy Manual for Medicare Services, Chapter I(V). 
 
The rules say that modifier 91 may be appended to laboratory procedure(s) or service(s) to indicate a repeat test 
or procedure on the same day when appropriate. If a HCPCS/CPT code has an MUE adjudicated as a claim line 
edit, (i.e., MAI equal to "1") appropriate use of CPT modifiers (i.e., 59 or -X{EPSU}, 76, 77, 91 anatomic) 
may be used to report the same HCPCS/CPT code on separate lines of a claim. This modifier indicates to the 
Medicare contractors that the physician had to perform a repeat clinical diagnostic laboratory test that was 
distinct or separate from a lab panel or other lab service performed on the same day and was performed to 
obtain medically necessary subsequent reportable test values. This modifier must not be used to report repeat 
laboratory testing due to laboratory errors, quality control, or confirmation of results.  
For example, if a laboratory performs all tests included in a panel of laboratory tests and repeats one of these 
component tests as a medically reasonable and necessary service on the same date of service, the HCPCS code 
corresponding to the repeat laboratory test may be reported with modifier 91 appended.  
 
You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9.1.1 (C). 
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare & Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1. 
 
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.