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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 for relative value units (RVUs) for services paid on the Physician Fee Schedule (PFS), the 
work component of physicians' services means the portion of the resources used in furnishing the service that 
reflects physician time and intensity. Beginning in 1998, the Centers for Medicare and Medicaid Services 
(CMS) was required to develop resource-based RVUs for practice expenses (PE). These take into consideration 
general expenses, such as office rent and wages of personnel.  
 
Separate PE RVUs are established for services furnished in facility settings, such as an ambulatory surgical 
center (ASC), and in non-facility settings, such as a physician's office. The non-facility RVUs reflect all of the 
direct and indirect PEs involved in furnishing a service described by a particular code. The difference, if any, in 
these PE RVUs generally results in a higher payment in the non-facility setting because in the facility settings 
some resource costs are borne by the facility. Medicares payment to the facility would reflect costs typically 
incurred by the facility. Thus, payment associated with those specific facility resource costs is not made under 
the PFS. You can find this information in the 2021 Physician Fee Schedule Final Rule, Section II, Subsection 
A(1)(a-b).  
 
The rules also say that ASC services are under the ASC payment system, Medicare makes facility payments to 
ASCs only for the specific ASC covered surgical procedures on the ASC list of covered surgical procedures. In 
addition, Medicare makes separate payment to ASCs for certain covered ancillary services that are provided 
integral to a covered ASC surgical procedure. ASC services for which payment is included in the ASC 
payment for a covered surgical procedure include nursing, technician, and related services; and, Materials, 
including supplies and equipment for the administration and monitoring of anesthesia. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 14, Section 10.2. 
 
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. 
 
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.