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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 state that Sections 1861(s)(2)(R) and 1861(pp) of the Social Security Act (the Act) and regulations at 
42 CFR 410.37 authorize Medicare coverage for screening colorectal cancer tests under Medicare Part B. The 
statute and regulations authorize the Secretary to add other tests and procedures (and modifications to tests and 
procedures for colorectal cancer screening) as the Secretary finds appropriate based on consultation with 
appropriate organizations. 
 
Nationally Covered Indications 
 
1.      Fecal Occult Blood Tests (FOBT) (effective January 1, 2004) 
Fecal occult blood tests (FOBTs) are generally divided into two types: immunoassay and guaiac types. 
Immunoassay (or immunochemical) fecal occult blood tests (iFOBT) use "antibodies directed against human 
globin epitopes. While most iFOBTs use spatulas to collect stool samples, some use a brush to collect toilet 
water surrounding the stool. Most iFOBTs require laboratory processing. 
Guaiac fecal occult blood tests (gFOBT) use a peroxidase reaction to indicate presence of the heme portion of 
hemoglobin. Guaiac turns blue after oxidation by oxidants or peroxidases in the presence of an oxygen donor 
such as hydrogen peroxide. Most FOBTs use sticks to collect stool samples and may be developed in a 
physician's office or a laboratory. In 1998, Medicare began reimbursement for guaiac FOBTs, but not 
immunoassay type tests for colorectal cancer screening. Since the fundamental process is similar for other 
iFOBTs, the Centers for Medicare & Medicaid Services evaluated colorectal cancer screening using 
immunoassay FOBTs in general. 

Effective for dates of service on and after January 1, 2004, Medicare covers one screening FOBT per annum 
for the early detection of colorectal cancer. This means that Medicare will cover one gFOBT or one iFOBT at a 
frequency of every 12 months; i.e., at least 11 months have passed following the month in which the last 
covered screening FOBT was performed, for beneficiaries aged 50 years and older. The beneficiary completes 
the existing gFOBT by taking samples from two different sites of three consecutive stools; the beneficiary 
completes the iFOBT by taking the appropriate number of stool samples according to the specific 
manufacturer's instructions. This screening requires a written order from the beneficiary's attending physician. 
("Attending physician" means a doctor of medicine or osteopathy (as defined in 1861(r)(1) of the Act) who is 
fully knowledgeable about the beneficiary's medical condition, and who would be responsible for using the results of any examination performed in the overall management of the beneficiary's specific medical 
problem.) 

Effective January 1, 2023, the minimum age for FOBT is reduced to 45 years and older. 
 
2.      The CologuardTM - Multi-target Stool DNA (sDNA) Test (effective October 9, 2014) 
Screening stool or fecal DNA (deoxyribonucleic acid, sDNA) testing detects molecular markers of altered 
DNA that are contained in the cells shed by colorectal cancer and pre-malignant colorectal epithelial neoplasia 
into the lumen of the large bowel. Through the use of selective enrichment and amplification techniques, sDNA 
tests are designed to detect very small amounts of DNA markers to identify colorectal cancer or pre-malignant 
colorectal neoplasia. The CologuardTM - multi-target sDNA test is a proprietary in vitro diagnostic device that 
incorporates both sDNA and fecal immunochemical test techniques and is designed to analyze patients' stool 
samples for markers associated with the presence of colorectal cancer and pre-malignant colorectal neoplasia. 
Effective for dates of service on or after October 9, 2014, The CologuardTM test is covered once every three 
years for Medicare beneficiaries that meet all of the following criteria: 
- Age 50 to 85 years, and, 
- Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower 
gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test (gFOBT) or fecal 
immunochemical test (iFOBT)), and, 
- At average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal 
cancer, or inflammatory bowel disease, including Crohn's Disease and ulcerative colitis; no family 
history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary 
nonpolyposis colorectal cancer). 

Effective January 1, 2023, the minimum age for sDNA is reduced to 45 years and older. 
 
3.      Blood-based Biomarker Tests (effective January 19, 2021) 
Blood-based DNA testing detects molecular markers of altered DNA that are contained in the cells shed into 
the blood by colorectal cancer and pre-malignant colorectal epithelial neoplasia. 
Effective for dates of service on or after January 19, 2021, a blood-based biomarker test is covered as an 
appropriate colorectal cancer screening test once every 3 years for Medicare beneficiaries when performed in a 
Clinical Laboratory Improvement Act (CLIA)-certified laboratory, when ordered by a treating physician and 
when all of the following requirements are met: 
The patient is: 
- age 50-85 years, and, 
- asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower 
gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical 
test), and, 
- at average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal 
cancer, or inflammatory bowel disease, including Crohn's Disease and ulcerative colitis; no family 
history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary 
nonpolyposis colorectal cancer). 
 
The blood-based biomarker screening test must have all of the following: 
- Food and Drug Administration (FDA) market authorization with an indication for colorectal cancer 
screening; and, 
- proven test performance characteristics for a blood-based screening test with both sensitivity greater 
than or equal to 74% and specificity greater than or equal to 90% in the detection of colorectal cancer compared to the recognized standard (accepted as colonoscopy at this time), as minimal threshold 
levels, based on the pivotal studies included in the FDA labeling. 
Effective January 1, 2023, the minimum age for blood-based biomarker test is reduced to 45 years and older. 
 
Nationally Non-Covered Indications 
All other indications for colorectal cancer screening not otherwise specified in the Act and regulations, or 
otherwise specified above remain nationally non-covered. Non-coverage specifically includes: 
(1) All screening sDNA tests, effective April 28, 2008, through October 8, 2014. Effective for dates of service 
on or after October 9, 2014, all other screening sDNA tests not otherwise specified above remain nationally 
non-covered. 
(2) Screening computed tomographic colonography (CTC), effective May 12, 2009. 
 
You can find this rule at the Medicare National Coverage Determination (NCD) 210.3: Colorectal Cancer 
Screening Tests. 
 
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.