Appeal type: Lab
Decision: Partially Favorable

 
You asked the Plan to pay for genetic tests. You say that these tests were performed at the request of the 
enrollee's in-network treating physician. The Plan says that the denial of payment for these services are correct, 
because there is no indication in the clinical record as to why these tests were performed, APC testing is not 
covered by Medicare under the conditions, and NRAS testing is not covered by Medicare under the conditions. 
 
We decided that the Plan does not have to pay for ADP testing with procedure code 81202 or NRAS 
testing with procedure code 81311 provided on March 13, 2020.  
 
The Plan follows Medicare rules. Medicare rules say that both ADP testing and NRAS testing have limited 
coverage. These tests are not covered when billed with primary diagnosis code C57.01. 
 
We looked at the file and Medicare rules. These tests were not billed with covered diagnosis codes. Therefore, 
we decided that the Plan does not have to pay for ADP and NRAS testing.  
 
We also decided that the Plan has to pay for genetic testing billed with procedure codes 81206 (BCR 
RNA), 81207 (BRC RNA), 81208 (BCR RNA), 81235 (EGFR), 81272 (KIT), 81275 (KRAS), 81276 
(KRAS), 81314 (PDGFRA), 81401 (PPARG RNA), 81401 (ETV6 RNA), 81403 (MPL), 81403 (JAK 2), 
81403 (MPL by DNA), 81403 (GNAQ), 81404 (CDKN2A), 81404 (FGFR2 by DNA), 81404 (FGFR2 by 
RNA), 81405 (SDHB), 81406 (RET), 81479 (AKT 1), 81479 (ARAF), 81479 (CDK 4), 81479 (CHEK 1), 
81479 (EGFRvIII), 81479 (ERBB2), 81479 (ESR1), 81479 (GNA 11), 81479 (GNAS), 81479 (MET), 81479 
(NPM 1), 81479 (NTRK1), 81479 (NTRK 2), 81479 (NTRK 3), 81479 (POLE), 81479 (PTPN 11), 81479 
(RSPO3), 81479 (SMARCE 1), and 88360 (PD-L1) provided on March 13, 2020. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that these 
tests would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment is correct or 
justified by Medicare rules. Therefore, we decided that the Plan must pay for these genetic tests provided on 
March 13, 2020. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.