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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 if one laboratory procedure evaluates multiple genes using a next generation sequencing 
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 CPT code. 
If no CPT code accurately describes the procedure performed, the laboratory may report CPT code 81479 
(Unlisted molecular pathology procedure) with one unit of service or may report multiple individual CPT codes 
describing the component test results when medically reasonable and necessary. Procedures reported together 
must be both medically reasonable and necessary (e.g., sequencing of procedures) and ordered by the physician 
who is treating the beneficiary and using the results in the management of the beneficiary's specific medical 
problem. You can find this information in Chapter X: Pathology/Laboratory Services (CPT codes 80000-8999) 
for National Correct Coding Initiative Policy Manual for Medicare Services. 
 
The rules state that when completing the 1500 claim form, providers must enter the correct Place of Service 
(POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. If the 
physician bills for lab services performed in his/her office, the POS code for "Office" is shown. If the physician 
bills for a lab test furnished by another physician, who maintains a lab in his/her office, the code for "Other" is 
shown. If the physician bills for a lab service furnished by an independent lab, the code for "Independent 
Laboratory" is used. Items 21 and 22 on the Form CMS-1500 must be completed for all laboratory work 
performed outside a physician's office. If an independent lab bills, the place where the sample was taken is 
shown. An independent laboratory taking a sample in its laboratory shows "81" as place of service. If an 
independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, it uses the 
code for the inpatient (POS code 21), off campus-outpatient hospital (POS code 19), or on campus-outpatient 
hospital (POS code 22), respectively. You can find this rule at Medicare Claims Processing Manual Chapter 26 
Section 10.6. 
 
The rules say that providers must report services correctly. Procedures should be reported with the CPT code 
that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative 
Manual, Chapter I.  
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can find this rule at 42 CFR 
Section 424.5. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.