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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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing 
(NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, 
molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis 
code. If no code accurately describes the procedure performed, the laboratory may report Current Procedural 
Terminology (CPT) code 81479 (Unlisted molecular pathology procedure) with one unit of service. You can 
find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, National 
Correct Coding Initiative (NCCI) Manual, Chapter 10, Section F(8). 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. An add-on code is eligible for payment 
only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on 
code is not eligible for payment if it is the only procedure reported by a practitioner. You can find this rule in 
the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 23, Section 20.9. The rules say that clinical diagnostic laboratory tests (CDLTs) making use of high throughput technologies (as defined in this Ruling) and administered during the ongoing emergency period defined in paragraph (1)(B) of section 1135(g) of the Act beginning on or after March 18, 2020, for the detection of SARS-CoV-2 or the 
diagnosis of the virus that causes Covid-19, are new and involve high throughput machines (which are highly 
sophisticated equipment) which require more intensive technician training (to ensure the role of extremely 
skilled personnel) and more time intensive processes (to assure quality). These tests are a type of CDLT 
currently paid for under Medicare Part B using codes U0003 and U0004. You can find this rule in the Centers 
for Medicare & Medicaid Services, Ruling Number CMS-2020-01-R. 
 
The rules say that beginning January 1, 2021, CMS will establish a new add-on payment of $25 as identified by 
HCPCS code U0005. As required by the HCPCS code U0005 descriptor, this add-on payment may be billed 
with either HCPCS code U0003 or HCPCS code U0004 when the applicable test is completed within 2 
calendar days of the specimen being collected. You can find this ruling in the Centers for Medicare and 
Medicaid Services, Ruling Number CMS-2020-1-R2. 
 
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.