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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 state that: 
Covered Indications 
1. Flow cytometry for cell surface, cytoplasmic, or nuclear marker will be considered medically 
reasonable and necessary when performed for the following indications: 
 Cytopenias and Hypercellular Hematolymphoid Disorder 
 Lymphomas 
 Acute Leukemia 
 Chronic Lymphocytic Leukemia (CLL) & Other Chronic Lymphoproliferative Diseases (CLPD) 
 Plasma Cell Disorders 
 Myelodysplastic Syndromes (MDS) 
 Chronic Myeloproliferative Disorders (CMPD) 
 Mast Cell Neoplasms 
 Paroxysmal Nocturnal Hemoglobinuria (PNH) 
 Minimal Residual Disease (MRD) 
 HIV Infection 
 Organ Transplants 
 DNA Analysis 
 Carcinoma, Non-hematolymphoid Tumors 
 Molar Pregnancy 
 Primary Immunodeficiencies (PDS) 
 Primary Platelet Disorders, non-neoplastic 
 Red Cell and White Cell Disorders, non-neoplastic 
 2. Flow cytometry-derived DNA content (ploidy),or cell proliferative activity (S-phase fraction), will be 
considered medically reasonable and necessary when performed for the following indications: 
 Mediastinum 
 Uterus 
 Ovary 
 Prostate 
 Bladder 
 Kidney/renal 
 Brain 
 Gastric 
 Breast 
 Colon 
 Rectal 
 Hydatidiform mole  
Limitations 
1. FCM immunophenotypes for most common lymphomas and leukemias are well characterized. FCM is 
NOT considered medically reasonable and necessary to perform more than twenty-four (24) markers in 
a panel. When atypical or unusual FCM results are obtained and the selective addition of more markers 
are indicated, the flow report must document the specific indication for each marker over the twenty-
four (24) limit. Any markers in excess of twenty-four (24) must be supported by documentation which 
clearly states the justification for the need for excess markers. 
2. Flow cytometry cell cycle or DNA analysis is indicated for a few selective groups of patients with 
certain carcinomas. Information obtained from flow cytometry is useful when the prognostic 
information will affect treatment decisions in patients with localized disease. It is usually performed one 
time after a diagnosis has been made and before treatment is initiated. 
3. Routine use of flow cytometry absent of clinical indication for its use will be considered screening and 
will not be allowed. 
4. For flow cytometry, cell cycle or DNA analysis, it is not expected that more than one unit total (given 
day or an episode of care) would be done for a patient with a covered indication. Therefore, utilization 
would be one time for a beneficiary with a given diagnosis (unless the patient had new disease) and 
generally should be performed before treatment is initiated. 
5. It is not expected that more than twenty-four (24) markers (cell surface, cytoplasmic, or nuclear) will be 
required. When more than twenty-four (24) markers are performed, documentation should support the 
medical necessity of the excess markers. 
You can find this rule at the Medicare Local Coverage Determination (LCD)-L33661: Flow Cytometry. 
 
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.