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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 a panel of genes is a distinct procedural service from a series of individual genes. All
services billed to Medicare must be reasonable and necessary. As such, if a provider or supplier submits a
claim for a panel, then the patient's medical record must reflect that the panel was reasonable and necessary.
Alternatively, if a provider or supplier bills for a number of individual genes, then the patient's medical record
must reflect that each individual gene is reasonable and necessary.
Genes can be assayed serially or in parallel. Genes assayed on the same date of service are considered to be
assayed in parallel if the result of one assay does not affect the decision to complete the assay on another gene,
and the two genes are being tested for the same indication. Genes assayed on the same date of service are
considered to be assayed serially when there is a reflexive decision component where the results of the analysis
of one or more genes determines whether the results of additional analyses are reasonable and necessary.
If a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be
considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS code must be
submitted for the panel. If the laboratory assays genes in serial, then the laboratory must submit claims for
genes individually. The order by the treating clinician must reflect whether the treating clinician is ordering a
panel or single genes, and additionally, the patient's medical record must reflect that the service billed was
reasonable and necessary.
When more than two codes from this list are submitted for the same beneficiary on the same date of service, the
claims processing system will reject every code submitted after the first two services. However, if a lab runs
more than two distinct procedural services from this list on a single date of service, then the lab must use the 59
modifier with each additional service billed as an attestation that it is a distinct procedural service.
You can find this rule in the Local Coverage Article: Billing and Coding: MoIDX: Testing of Multiple Genes
(A57880).
Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the health plan
sufficient information to determine whether payment is due and the amount of payment. You can find this rule
at 42 CFR Section 424.5.
The rules say for Medicare to consider coverage and payment for any item or service, the information
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Medicare
Program Integrity Manual Chapter 3 Section 3.3.2.1.
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.