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Decision: unknown

 
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. 
Molecular pathology procedures have broad clinical and research applications. The following examples of 
applications may not be relevant to a Medicare beneficiary or may not meet a Medicare benefit category and/or 
reasonable and necessary threshold for coverage. Such examples include Genetic Testing and Genetic 
Counseling (when applicable) for: 
 
- Disease Risk, 
- Carrier Screening, 
- Hereditary Cancer Syndromes, 
- Gene Expression Profiling for certain cancers, 
- Prenatal Diagnostic testing, 
- Diagnosis and Monitoring Non-Cancer Indications, and 
- Several Pharmacogenomic applications. 
 
This Local Coverage Determination (LCD) addresses the circumstances under which the item or service may 
be reasonable and necessary. For laboratory services, a service may be reasonable and necessary if the service 
is safe and effective; and appropriate, including the duration and frequency that is considered appropriate for 
the item or service, in terms of whether it is furnished in accordance with accepted standards of medical 
practice for the diagnosis of the patient's condition; furnished in a setting appropriate to the patient's medical 
needs and condition; ordered and furnished by qualified personnel; one that meets, but does not exceed, the 
patient's medical need; and is at least as beneficial as an existing and available medically appropriate 
alternative. 
 
Indications: 
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). 
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.