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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 molecular pathology procedures (Tier1 and Tier 2) may be eligible for coverage when ALL 
of the following criteria are met: 
 
1. Alternative laboratory or clinical tests to definitively diagnose the disorder/identify the condition are 
unavailable or results are clearly equivocal; AND 
2. Availability of a clinically valid test, based on published peer reviewed medical literature; AND 
3. 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 
4. Results of the testing must directly impact treatment or management of the Medicare beneficiary; AND 
5. 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 
6. 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. 
 
You can find this rule in the Local Coverage Determination (LCD) - Molecular Pathology Procedures (L35000) 
- Effective July 1, 2020. 
 
The rules say that CALR (calreticulin) (eg, myeloproliferative disorders), gene analysis, common variants in 
exon 9 is considered medically necessary in the initial diagnostic work-up of BCR-ABL negative, JAK2-
negative adults with clinical, laboratory, or pathological findings suggesting polycythemia vera (PV), essential 
thrombocythemia (ET) or primary myelofibrosis (PMF). You can find this rule in the Local Coverage 
Determination (LCD) - Molecular Pathology Procedures (L35000) - Effective July 1, 2020. 
 
The rules say that JAK2 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) 
(eg, myeloproliferative disorder), exon 12 sequence and exon 13 sequence is 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) - Effective July 1, 2020. 
 
The rules say that MPL (myeloproliferative leukemia virus oncogene, thrombopoietin receptor, TPOR) (eg, 
myeloproliferative disorder), exon 10 sequence is considered medically necessary in the initial work-up of 
BCR-ABL negative, JAK2 negative, and CALR negative adults with clinical, laboratory, or pathological 
findings suggesting thrombocytosis, essential thrombocythemia (ET), or primary myelofibrosis (PMF). You 
can find this rule in the Local Coverage Determination (LCD) - Molecular Pathology Procedures (L35000) - 
Effective July 1, 2020. 
 
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.