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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 screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
The rules also state that under preventative services, Medicare Part B covers the basic lipid panel (total 
cholesterol, high density lipoprotein-cholesterol (HDL-C), triglycerides, and low density lipoprotein-
cholesterol (LDL-C)) for cardiovascular (CV) disease screening, every 5 years when ordered by a doctor. 
 
NCD 190.23 covers lipid panel testing for symptomatic patients for evaluating atherosclerotic CV disease, to 
monitor the progress of patients on anti-lipid dietary management and pharmacologic therapy for various lipid 
disorders. Per NCD 190.23, "Routine screening and prophylactic testing for lipid disorders are not covered by 
Medicare. While lipid screening may be medically appropriate, Medicare by statue does not pay for it. Lipid 
testing in asymptomatic individuals is considered to be screening regardless of the presence of other risk 
factors such as family history, tobacco use, etc."  

This policy denies coverage for all CV risk assessment panels, except the basic lipid panel, for symptomatic 
(with signs and symptoms) patients with suspected or documented CV disease because panel testing is not 
specific to a given patient's lipid abnormality or disease. The policy indicates the medical indication(s) based 
on published scientific articles and consensus guidelines for individual lipid biomarkers that may be covered to 
characterize a given lipid abnormality or disease, to determine a treatment plan or to assist with intensification 
of therapy. Each individual lipid biomarkers must be specifically ordered and the reason for the test order 
documented in the patient's medical record. The policy denies coverage for all non-lipid biomarkers when used 
for CV risk assessment including but not limited to, biochemical, immunologic, and hematologic, and genetic 
biomarkers for CV risk assessment regardless of whether ordered in a panel or individually. You can find this 
information in Local Coverage Determination (LCD): MolDX: Biomarkers in Cardiovascular Risk Assessment 
(L36362). 
 
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.