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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 medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 

The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o). 

Pathologists are often called upon to microscopically diagnose abnormalities seen on endoscopic exam of the esophagus, stomach, duodenum and colon. Biopsy specimens constitute an important diagnostic patient service. Most normal and abnormal conditions of these organs can be detected by the use of the routine H&E stain alone. 

Only the pathologist may determine the medical necessity of a special stain. Ordering special stains or IHC stains prior to review of the routine H&E stain is not reasonable and necessary. For most esophageal, gastric and duodenal specimens, it is not reasonable or necessary to perform special stains such as alcian blue - periodic acid Schiff (AB-PAS), or other mucin stains, such as diastase - PAS (D-PAS), or IHC stains such CDX-2 to determine if clinically meaningful intestinal metaplasia is present. In addition, it is not usually reasonable and necessary to perform special stains or IHC to determine the presence of H. pylori organisms. 

Other examples of special stains or IHC that are not reasonable and necessary on every specimen include:

Esophagus - fungal stains, trichrome, DPAS, CDX-2 or other mucin stains 
Gastric - AB-PAS, D-PAS, CDX-2 or other mucin stains, or special stains or IHC for H. pylori, or neuroendocrine markers such as synaptophysin or chromogranin

Duodenum - AB-PAS, D-PAS, CD3, and trichrome, or other mucin stains 
Colon - CD3, p53 trichrome 
Hyperplastic polyps - Ki67, CK20, p53, CEA, BRAF 
Tubular or tubulovillous adenoma - Ki-67, CK20, CEA, p53, MMR

If special stains or IHC are needed in addition to the routine H&E for gastric specimens, specific documentation to justify the medical necessity for the stain is required in the pathology report. Cases that may require special stains or IHC include but are not limited to the following:

Detection of H pylori in an appropriate milieu when organisms are not seen on H&E stained slides; 
Evaluating atrophic gastritis for evidence of autoimmune etiology and for enterochromaffin-like (ECL) cell hyperplasia/carcinoid tumor 
Characterizing a carcinoma, lymphoma, melanoma or sarcoma 
Defining a GIST tumor and to distinguish it from mimics 
Ki-67 by IHC in the differential diagnosis of certain neuroendocrine tumors of the gut

Scientific data demonstrates that the combined number of gastric biopsies requiring special stains or IHC is roughly 20% of biopsies received and examined in a pathology practice. GI specialty practices with a large GI referral base or GI consultant pathologists may sometimes exceed this relative number of special stains/IHC, but one would not expect to see routine high utilization of special stains or IHC. To check utilization, we encourage providers to perform a self-audit on the number of separate gastric biopsies as compared to ancillary stains. The ancillary stain group should be less than 20% of the total gastric biopsies submitted. Providers that exceed the 20% criteria may be subject to additional action.

Over-utilization of special stains has also been observed with duodenal biopsies where CD3 and AB/D-PAS are reportedly used to help exclude intraepithelial lymphocytosis and gastric metaplasia. Both of these conditions, if present, are easily recognizable on H&E morphology. Mucin stains such as AB-PAS or DPAS would be reasonable and necessary in limited circumstances, and rarely is CD3 warranted on duodenal biopsies which show villous architectural abnormalities.

Architectural and histologic features define colonic polyps including hyperplastic, inflammatory, and adenomatous lesions. Special stains and/or IHC stains are not reasonable and necessary for colon polyps despite textbooks noting, for example, thickened subepithelial collagen demonstrated by trichrome or collagen staining in hyperplastic polyps, or carcinoembryonic antigen (CEA) overexpression in hyperplastic polyps. While the information is of academic interest, special stains are not reasonable and necessary to make the diagnosis of various colonic polyps.

Lynch Syndrome (LS) tumor screening for DNA mismatch repair (MLH1, MSH2, MSH6 and PMS2) by qualitative IHC and/or microsatellite instability (MSI) is considered medically necessary and covered by Medicare for the following indications:

All individuals with colorectal cancer diagnosed at age =70 years of age, and those > 70 years of age who meet the revised Bethesda guidelines OR Individuals with endometrial cancer

No definitive algorithm for LS screening has been recommended. However, if IHC is done first and is abnormal, MSI testing is not warranted. If IHC is normal, MSI may be warranted. IHC testing LS is qualitative and does not require the use of tumor morphometry.

You can find these rules in Local Coverage Determination (LCD): Lab: Special Histochemical Stains and Immunohistochemical Stains (L36805).

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.