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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 Nationally Covered Indications:

1. Somatic (Acquired) Cancer: Effective for services performed on or after March 16, 2018, the Centers for
Medicare & Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic
laboratory test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory
Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of
the following requirements are met: a. Patient has: i. either recurrent, relapsed, refractory, metastatic, or
advanced stage III or IV cancer; and, ii. not been previously tested with the same test using NGS for the same
cancer genetic content, and, iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). b.
The diagnostic laboratory test using NGS must have: i. Food & Drug Administration (FDA) approval or
clearance as a companion in vitro diagnostic; and ii. an FDA-approved or -cleared indication for use in that
patient's cancer; and iii. results provided to the treating physician for management of the patient using a report
template to specify treatment options.

Germline (Inherited) Cancer: Effective for services performed on or after January 27, 2020, CMS has
determined that NGS as a diagnostic laboratory test is reasonable and necessary and covered nationally for
patients with germline (inherited) cancer, when performed in a CLIA-certified laboratory, when ordered by a
treating physician and when all of the following requirements are met: a. Patient has: i. ovarian or breast
cancer; and, ii. a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer; and,
iii. a risk factor for germline (inherited) breast or ovarian cancer; and iv. not been previously tested with the
same germline test using NGS for the same germline genetic content. b. The diagnostic laboratory test using
NGS must have all of the following: i. FDA-approval or clearance; and, ii. results provided to the treating
physician for management of the patient using a report template to specify treatment options.

1. Somatic (Acquired) Cancer: Effective for services performed on or after March 16, 2018, NGS as a
diagnostic laboratory test for patients with acquired (somatic) cancer are non-covered if the cancer patient does
not meet the criteria noted in section B.1., above.

1. Somatic (Acquired) Cancer: Effective for services performed on or after March 16, 2018, Medicare
Administrative Contractors (MACs) may determine coverage of NGS as a diagnostic laboratory test for
patients with advanced cancer only when the test is performed in a CLIA-certified laboratory, when ordered by
a treating physician, and when the patient has: a. either recurrent, relapsed, refractory, metastatic, or advanced
stages III or IV cancer; and, b. not been previously tested with the same test using NGS for the same cancer
genetic content, and c. decided to seek further cancer treatment (e.g., therapeutic chemotherapy).

2. Germline (Inherited) Cancer: Effective for services performed on or after January 27, 2020, MACs may
determine coverage of NGS as a diagnostic laboratory test for patients with germline (inherited) cancer only
when the test is performed in a CLIA-certified laboratory, when ordered by a treating physician, when results
are provided to the treating physician for management of the patient and when the patient has: a. any cancer
diagnosis; and, b. a clinical indication for germline (inherited) testing of hereditary cancers; and, c. a risk factor
for germline (inherited) cancer; and, d. not been previously tested with the same germline test using NGS for
the same germline genetic content.

You can find this information in Medicare's National Coverage Determination (NCD): Next Generation
Sequencing (NGS) (90.2).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.