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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 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 an Outpatient Prospective Payment System (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.  
 
Each HCPCS code for which separate payment is made under the OPPS is assigned to an ambulatory payment 
classification (APC) group. The payment rate and coinsurance amount calculated for an APC apply to all of the 
services assigned to the APC. The comprehensive APC payment policy packages payment for adjunctive items, 
services, and procedures into the most costly primary procedures under the OPPS at the claim level. When non-
therapy outpatient department services are included on the same claim as a C-APC procedure (status indicator 
(SI) = J1), these services are considered adjunctive to the primary procedure. Payment for nontherapy 
outpatient department services is included as a packaged part of the payment for the C-APC procedure. This 
includes all covered Part B services on the claim with the primary "J1" service for the claim, except services 
with OPPS status indicator of "F","G", "H", "L" and "U"; ambulance services; diagnostic and screening mammography; rehabilitation therapy services; services assigned to a new technology APC; self-administered 
drugs; all preventive services; and certain Part B inpatient services; and FDA-authorized or approved drugs and 
biologicals (including blood products) that are authorized or approved to treat or prevent COVID-19. 
 
You can find this information in the Centers for Medicare & Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Sections 10.1.1, 10.2 and 10.2.4. 
 
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.