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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 This policy provides coverage for multi-gene non-next generation sequencing (NGS) panel 
testing and NGS testing for the diagnostic workup for myeloproliferative disease (MPD), also known as 
myeloproliferative neoplasms (MPNs), and limited coverage for single-gene testing of patients with BCR-ABL 
negative MPD. BCR-ABL negative MPD includes polycythemia vera (PV), essential thrombocythemia (ET), 
and primary myelofibrosis (PMF). 
 
For laboratories performing single gene technologies, a sequential genetic testing approach is expected. Once a 
positive result is obtained and the appropriate diagnosis is established, further testing should stop. Reflex 
testing to the next gene will be considered reasonable and necessary if the following sequence of genetic tests 
produce a negative result: 
 
    BCR-ABL negative test results, progress to #2 
    JAK 2, cv negative test results, progress to #3 or #4 
    JAK, exon 12 (JAK2 exon 12 is only done when PV is suspected) 
    Calreticulin (CALR)/MPL (CALR/MPL is only done when either ET or PMF is suspected; testing for 
CALR/MPL does NOT require a negative JAK2 exon 12, just a negative JAK2 V617F result) 
 
Genetic testing of the JAK2 V617F mutation is medically necessary when the following criteria are met: 
 
    Genetic testing impacts medical management; and 
    Patient would meet World Health Organizations (WHO) diagnostic criteria for myeloproliferative disease 
(i.e., PV, ET, PMF) if JAK2 V617F were identified. 
 
Genetic testing of JAK2 exon 12, performed to identify PV, is medically necessary when the following criteria 
are met: 
 
    Genetic testing impacts medical management; and 
    Patient would meet WHO's diagnostic criteria for PV, if JAK2 exon 12 testing were positive; and 
    JAK2 V617F mutation analysis was previously completed and was negative. 
 
You can find this rule in the Local Coverage Determination (LCD) MolDX: Genetic Testing for BCR-ABL 
Negative Myeloproliferative Disease L36186. 
  The rules say Molecular pathology procedures (Tier1 and Tier 2) may be eligible for coverage when ALL of 
the following criteria are met: 
 
    Alternative laboratory or clinical tests to definitively diagnose the disorder/identify the condition are 
unavailable or results are clearly equivocal; AND 
    Availability of a clinically valid test, based on published peer reviewed medical literature; AND 
    Testing assay(s) are Food and Drug Administration (FDA) approved/cleared or if LDT (lab developed test) 
or LDT protocol or FDA modified test(s) the laboratory documentation should support assay(s) of analytical 
validity and clinical utility; AND 
    Results of the testing must directly impact treatment or management of the Medicare beneficiary; AND 
    For testing panels, including but not limited to, multiple genes or multiple conditions, and in cases where a 
tiered approach/method is clinically available, testing would be covered ONLY for the number of genes or test 
that are reasonable and necessary to obtain necessary information for therapeutic decision making; AND 
    Individual has not previously received genetic testing for the disease/condition. (In general, diagnostic 
genetic testing for a disease should be performed once in a lifetime.) Exceptions include clinical scenarios 
whereby repeat testing of somatically acquired mutations (for example, pre- and post- therapy) may be required 
to inform appropriate therapeutic decision-making. 
 
    Any procedures required prior to cell lysis should be reported separately and utilization must be clearly 
supported based on the application and clinical utility. Such claims may be subject to prepayment medical 
review. 
    The medically necessary interpretation and report of a molecular pathology test, written by a pathologist, 
which is above and beyond the report of standard laboratory results may not be reported by Non- physician 
practitioners (e.g., PhD, scientists etc.); only physicians are eligible to report this service. 
    Testing for quality assurance component of the service is not separately billable. 
 
AK2 V617F genotyping is considered medically necessary in the initial diagnostic work-up of BCR-ABL 
negative, JAK2-negative adults with clinical, laboratory, or pathological findings suggesting myeloproliferative 
neoplasm (MPN) (polycythemia vera (PV), essential thrombocythemia (ET) or primary myelofibrosis (PMF)) 
or a myelodysplastic syndrome (MDS). Note: JAK2 (exons 12 and 13) (reported with 81403) is medically 
necessary in individuals for whom PV is a strong consideration. 
 
JAK2 (Janus kinase 2) (e.g., myeloproliferative disorder), exon 12 sequence and exon 13 sequence are 
considered medically necessary in the initial work-up of BCR-ABL and JAK2 (V617F variant) negative adults 
with clinical, laboratory, or pathological findings suggesting polycythemia vera. You can find this rule in the 
Local Coverage Determination (LCD) Molecular Pathology Procedures L35000. 
 
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.