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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 screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
The rules say cardiovascular disease screening (blood) tests are defined as "A lipid panel consisting of a total 
cholesterol, HDL cholesterol and triglyceride. The test is performed after a 12-hour fasting period." 
Furthermore, "Medicare Part B covers cardiovascular disease screening tests when ordered by the physician 
who is treating the beneficiary for the purpose of early detection of cardiovascular disease in individuals 
without apparent signs or symptoms of cardiovascular disease. You can find this information in Medicare's 
Code of Federal Regulation (CFR) 42 CFR 410, Subpart B - Medical and Other Health Services Section 
410.17. 
 The rules say in the case of cardiovascular disease screening tests for the early detection of cardiovascular 
disease or abnormalities associated with an elevated risk for that disease, subject to the conditions specified in 
Section 410.17 of this chapter." Genetic cardiovascular screening testing does not meet the definition of 
cardiovascular disease screening as outlined by Section 410.17, as indicated above, and thus is excluded from 
Medicare coverage. You can find this information in Medicare's 42 CFR 411, Subpart A - Exclusions from 
Medicare and Limitations on Medicare Payment Section 411.15 - Particular services excluded from coverage, 
paragraph (k)(13). 
 
The rules say under preventative services, Medicare Part B covers the basic lipid panel (total cholesterol, high 
density lipoprotein-cholesterol (HDL-C), triglycerides, and low-density lipoprotein-cholesterol (LDL-C) for 
cardiovascular (CV) disease screening, every 5 years when ordered by a doctor. This policy denies coverage 
for all CV risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) 
patients with suspected or documented CV disease because panel testing is not specific to a given patients 
lipid abnormality or disease. The policy indicates the medical indication(s) based on published scientific 
articles and consensus guidelines for individual lipid biomarkers that may be covered to characterize a given 
lipid abnormality or disease, to determine a treatment plan or to assist with intensification of therapy. Each 
individual lipid biomarkers must be specifically ordered and the reason for the test order documented in the 
patients medical record. The policy denies coverage for all non-lipid biomarkers when used for CV risk 
assessment including but not limited to, biochemical, immunologic, and hematologic, and genetic biomarkers 
for CV risk assessment regardless of whether ordered in a panel or individually. You can find this information 
in Medicare's Local Coverage Determination (LCD) for MolDX: BIOMARKERS IN CARDIOVASCULAR 
RISK ASSESSMENT (L36358). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.