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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 glycated hemoglobin/protein testing is widely accepted as medically necessary for the 
management and control of diabetes. It is also valuable to assess hyperglycemia, a history of hyperglycemia or 
dangerous hypoglycemia. Glycated protein testing may be used in place of glycated hemoglobin in the 
management of diabetic patients, and is particularly useful in patients who have abnormalities of erythrocytes 
such as hemolytic anemia or hemoglobinopathies. You can find this rule in the National Coverage 
Determination (NCD) - Glycated Hemoglobin/Glycated Protein (190.21) - Effective November 25, 2002. 
 
The rules say that testing of patients who are asymptomatic, or who do not have a condition that could be 
expected to result in a hematological abnormality, is screening and is not a covered service. You can find this 
rule in the National Coverage Determination (NCD) - Blood Counts (190.15) - Effective November 25, 2002. 
 
The rules say that indications for a complete blood count (CBC) or hemogram include red cell, platelet, and 
white cell disorders. Examples of these indications are enumerated individually below. 
 
1. Indications for a CBC generally include the evaluation of bone marrow dysfunction as a result of neoplasms, 
therapeutic agents, exposure to toxic substances, or pregnancy.  The CBC is also useful in assessing peripheral 
destruction of blood cells, suspected bone marrow failure or bone marrow infiltrate, suspected 
myeloproliferative, myelodysplastic, or lymphoproliferative processes, and immune disorders. 
2. Indications for hemogram or CBC related to red cell (RBC) parameters of the hemogram include signs, 
symptoms, test results, illness, or disease that can be associated with anemia or other red blood cell disorder 
(e.g., pallor, weakness, fatigue, weight loss, bleeding, acute injury associated with blood loss or suspected 
blood loss, abnormal menstrual bleeding, hematuria, hematemesis, hematochezia, positive fecal occult blood 
test, malnutrition, vitamin deficiency, malabsorption, neuropathy, known malignancy, presence of acute or 
chronic disease that may have associated anemia, coagulation or hemostatic disorders, postural dizziness, 
syncope, abdominal pain, change in bowel habits, chronic marrow hypoplasia or decreased RBC production, 
tachycardia, systolic heart murmur, congestive heart failure, dyspnea, angina, nailbed deformities, growth 
retardation, jaundice, hepatomegaly, splenomegaly, lymphadenopathy, ulcers on the lower extremities). 
3. Indications for hemogram or CBC related to red cell (RBC) parameters of the hemogram include signs, 
symptoms, test results, illness, or disease that can be associated with polycythemia (for example, fever, chills, 
ruddy skin, conjunctival redness, cough, wheezing, cyanosis, clubbing of the fingers, orthopnea, heart murmur, 
headache, vague cognitive changes including memory changes, sleep apnea, weakness, pruritus, dizziness, 
excessive sweating, visual symptoms, weight loss, massive obesity, gastrointestinal bleeding, paresthesias, dyspnea, joint symptoms, epigastric distress, pain and erythema of the fingers or toes, venous or arterial 
thrombosis, thromboembolism, myocardial infarction, stroke, transient ischemic attacks, congenital heart 
disease, chronic obstructive pulmonary disease, increased erythropoietin production associated with neoplastic, 
renal or hepatic disorders, androgen or diuretic use, splenomegaly, hepatomegaly, diastolic hypertension.) 
4. Specific indications for CBC with differential count related to the WBC include signs, symptoms, test 
results, illness, or disease associated with leukemia, infections or inflammatory processes, suspected bone 
marrow failure or bone marrow infiltrate, suspected myeloproliferative, myelodysplastic or lymphoproliferative 
disorder, use of drugs that may cause leukopenia, and immune disorders (e.g., fever, chills, sweats, shock, 
fatigue, malaise, tachycardia, tachypnea, heart murmur, seizures, alterations of consciousness, meningismus, 
pain such as headache, abdominal pain, arthralgia, odynophagia, or dysuria, redness or swelling of skin, soft 
tissue bone, or joint, ulcers of the skin or mucous membranes, gangrene, mucous membrane discharge, 
bleeding, thrombosis, respiratory failure, pulmonary infiltrate, jaundice, diarrhea, vomiting, hepatomegaly, 
splenomegaly, lymphadenopathy, opportunistic infection such as oral candidiasis.) 
5. Specific indications for CBC related to the platelet count include signs, symptoms, test results, illness, or 
disease associated with increased or decreased platelet production and destruction, or platelet dysfunction(e.g., 
gastrointestinal bleeding, genitourinary tract bleeding, bilateral epistaxis, thrombosis, ecchymosis, purpura, 
jaundice, petechiae, fever, heparin therapy, suspected DIC, shock, pre-eclampsia, neonate with maternal ITP, 
massive transfusion, recent platelet transfusion, cardiopulmonary bypass, hemolytic uremic syndrome, renal 
diseases, lymphadenopathy, hepatomegaly, splenomegaly, hypersplenism, neurologic abnormalities, viral or 
other infection, myeloproliferative, myelodysplastic, or lymphoproliferative disorder, thrombosis, exposure to 
toxic agents, excessive alcohol ingestion, autoimmune disorders (SLE, RA and other). 
6. Indications for hemogram or CBC related to red cell (RBC) parameters of the hemogram include, in addition 
to those already listed, thalassemia, suspected hemoglobinopathy, lead poisoning, arsenic poisoning, and 
spherocytosis. 
7. Specific indications for CBC with differential count related to the WBC include, in addition to those already 
listed, storage diseases/mucopolysaccharidoses, and use of drugs that cause leukocytosis such as G-CSF or 
GM-CSF. 
8. Specific indications for CBC related to platelet count include, in addition to those already listed, May-
Hegglin syndrome and Wiskott-Aldrich syndrome. 
 
You can find this rule in the National Coverage Determination (NCD) - Blood Counts (190.15) - Effective 
November 25, 2002. 
 
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.