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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.  

Medicare guidance says, physicians must report services correctly. This manual discusses general coding principles in Chapter I and principles more relevant to other specific groups of HCPCS/CPT codes in the other chapters. There are certain types of improper coding that physicians must avoid. You can find this Medicare guidance in the National Correct Coding Initiative Policy Manual, Chapter I General Correct Coding Policies, Section A. Introduction. On the Medicare web site, CMS.gov, PFS Relative Value Files, the file 2021 National Physician Fee Schedule Relative Value File January Release lists HCPCS - 88305, MOD field has a Blank and the PCTC IND field is entered with - 1.  

Medicare guidance says, the CMS MPFSDB includes the total fee schedule amount, related component parts, and payment policy indicators. The record layout is provided in the Addendum below. Field Name & Description - Modifier, for diagnostic tests, a blank in this field denotes the global service and the following modifiers identify the components: 26 = Professional component, TC = Technical component. Field Name & Description - Professional Component (PC)/Technical Component (TC) Indicator, 1 = Diagnostic tests or radiology services: This indicator identifies codes that describe diagnostic tests, e.g., pulmonary function tests, or therapeutic radiology procedures, e.g., radiation therapy. These codes generally have both a professional and technical component. Modifiers 26 and TC can be used with these codes. The total RVUs for codes reported with a 26 modifier include values for physician work, practice expense, and malpractice expense. The total RVUs for codes reported with a TC modifier include values for practice expense and malpractice expense only. The total RVUs for codes reported without a modifier equals the sum of RVUs for both the professional and technical component. You can find this guidance in the Medicare Claims Processing Manual, Chapter 23 - Fee Schedule Administration and Coding Requirements, Section 30.2 - MPFSDB Record Layout and Section 50.6 - Physician Fee Schedule Payment Policy Indicator File Record Layout.   

Medicare guidance says, A/B MACs (B) may not pay for the technical component (TC) of radiology services furnished to hospital patients. Payment for physicians' radiological services to the hospital, e.g., administrative or supervisory services, and for provider services needed to produce the radiology service, is made by the AB MAC (A) to the hospital as a provider service. Radiology and other diagnostic services furnished to hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the hospital. This applies to bill types 12X and 13X that are submitted to the AB MAC (A). Effective 4/1/06, type of bill 14X is for non-patient laboratory specimens and is no longer applicable for radiology services. You can find this guidance in the Medicare Claims Processing Manual, Chapter 13 - Radiology Services and Other Diagnostic Procedures, Section 20.2 - Technical Component (TC), Section 20.2.1 - Hospital and Skilled Nursing Facility (SNF) Patients.  

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.