Appeal type: unknown
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. 
 
The rules say that many applications of the molecular pathology procedures are not covered services given lack 
of benefit category (e.g., preventive service or screening for a genetic abnormality in the absence of a suspicion 
of disease) and/or failure to the reasonable and necessary threshold for coverage (e.g., based on quality of 
clinical evidence and strength of recommendation or when the results would not reasonably be used in the 
management of a beneficiary). Furthermore, payment of claims in the past (based on stacking codes) or in the 
future (based on the new code series) is not a statement of coverage since the service may not have been 
audited for compliance with program requirements and documentation supporting the reasonable and necessary 
testing for the beneficiary. Certain molecular pathology procedures may be subject to prepayment medical 
review (records requested) and paid claims must be supportable, if selected, for post payment audit by the 
MAC or other contractors. Molecular pathology tests for diseases or conditions that manifest severe signs or 
symptoms in newborns and in early childhood or that result in early death (e.g., Canavan disease) could be 
subject to automatic denials since these tests are not usually relevant to a Medicare beneficiary. 
 
Molecular pathology procedures (Tier1 and Tier 2) may be eligible for coverage when ALL of the following 
criteria are met: 
    Alternative laboratory or clinical tests to definitively diagnose the disorder/identify the condition are 
unavailable or results are clearly equivocal; AND 
    Availability of a clinically valid test, based on published peer reviewed medical literature; AND 
    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 
    Results of the testing must directly impact treatment or management of the Medicare beneficiary; AND 
    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 
    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.  Limitations: 
    Any procedures required prior to cell lysis should be reported separately and utilization must be clearly 
supported based on the application and clinical utility. Such claims may be subject to prepayment medical 
review. 
    The medically necessary interpretation and report of a molecular pathology test, written by a pathologist, 
which is above and beyond the report of standard laboratory results may not be reported by Non- physician 
practitioners (e.g., PhD, scientists etc.); only physicians are eligible to report this service. 
    Testing for quality assurance component of the service is not separately billable. 
 
You can find these rules 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.