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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 Comprehensive Genomic Profile (CGP) Next Generation Sequence (NGS) testing for 
patients with advanced cancer is reasonable and necessary only when performed in a Clinical Laboratory 
Improvement Amendments (CLIA) certified laboratory, when ordered by a treating physician, and when the 
patient has: 
 
either recurrent, relapsed, refractory, metastatic, or advanced stages III or IV cancer; and 
not been previously tested with a CGP for the same cancer genetic content; and 
decided to seek further cancer treatment (e.g., therapeutic chemotherapy) 
Additionally, the test performed must be able to detect at least the minimum genes and genomic positions 
required for the identification of clinically supported, FDA-approved therapies. The genes and genomic 
positions required are listed in Category 1 or 2A of the most current version of the National Comprehensive 
Cancer Network (NCCN) Biomarkers Compendium (2). Testing assays must be FDA approved/cleared, or if a 
laboratory developed test (LDT), have a published, peer-reviewed study supporting analytic validity, or 
certification by a third-party consistent with the New York State Department of Healths Clinical Laboratory 
Evaluation Program (CLEP) review standards. 
 
You can find this information in the Local Coverage Determination (LCD): Genomic Sequence Analysis 
Panels in the Treatment of Solid Organ Neoplasms (L37810). 
 
The rules say that 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: 
 
1. Patient has: 
 
-either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and,  
-either not been previously tested using the same NGS test for the same primary diagnosis of cancer, or repeat 
testing using the same NGS test only when a new primary cancer diagnosis is made by the treating physician; 
and,  
-decided to seek further cancer treatment (e.g., therapeutic chemotherapy).  2. The diagnostic laboratory test using NGS must have: 
- Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and,  
- an FDA-approved or -cleared indication for use in that patients cancer; and,  
- results provided to the treating physician for management of the patient using a report template to specify 
treatment options.  
 
You can find this rule in National Coverage Determination (NCD) for Next Generation Sequencing (NGS) 
(90.2) - Effective March 16, 2018. 
 
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.