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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 screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
Medicare guidance says "A lipid panel consisting of a total cholesterol, HDL cholesterol and triglyceride. The 
test is performed after a 12-hour fasting period." Furthermore, "Medicare Part B covers cardiovascular disease 
screening tests when ordered by the physician who is treating the beneficiary for the purpose of early detection 
of cardiovascular disease in individuals without apparent signs or symptoms of cardiovascular disease." You 
can find this guidance in the Code of Federal Regulation 42 CFR 410, Subpart B - Medical and Other Health Services Section 410.17.  
 
Medicare guidance says, in the case of cardiovascular disease screening tests for the early detection of 
cardiovascular disease or abnormalities associated with an elevated risk for that disease, subject to the 
conditions specified in Section 410.17 of this chapter. Genetic cardiovascular screening testing does not meet 
the definition of cardiovascular disease screening as outlined by Section 410.17, as indicated above, and thus is 
excluded from Medicare coverage. You can find this guidance in the Code of Federal Regulation 42 CFR 411, 
Subpart A - Exclusions from Medicare and Limitations on Medicare Payment Section 411.15 
 
Medicare guidance says CPT code 80061 (Lipid panel) which includes CPT codes: 82465 (Cholesterol, serum 
or whole blood, total), 83718 (Lipoprotein, direct measurement; high density cholesterol) and/or 84478 
(Triglycerides).You can find this guidance in the Medicare Claims Processing Manual Chapter 18 - Preventive 
and Screening Services Section 100.1 
 
Per Medicare guidance says Covered Indications Genetic testing for hereditary cardiovascular disease will be 
considered medically reasonable and necessary if: The patient has rigorous disease-appropriate phenotyping to 
establish clinical diagnosis or suspected diagnosis for which the test results would directly impact the 
management of the patients condition, prior to ordering the test AND 1. The evidence for the gene-disease 
association is evaluated by the evidence-based, transparent, peer-reviewed process of the National Institutes of 
Health (NIH) sponsored Clinical Genome Resource (ClinGen) and is determined to demonstrate actionability 
in clinical decision making, meeting all bulleted metrics: Disease severity of sudden death, possible death or 
major morbidity, modest morbidity. Substantial or moderate evidence of a greater than 40% likelihood of 
disease Substantial or moderate evidence of a highly effective or moderately effective intervention. The nature 
of intervention is either low risk/medically acceptable/low intensity intervention or moderately 
acceptable/risk/intensive interventions, AND 2. Clinical validity and qualitative descriptors from Moderate, 
Strong & Definitive with contradictory evidence NOT being reported as disputed or refuted. Limitations The 
following are considered not medically reasonable and necessary: 1. A genetic test where either analytical 
validity, clinical validity, or clinical utility has not been established. Genetic testing in patients who do not 
demonstrate the disease-appropriate phenotype of the gene-disease association. 2. 3. Genetic testing of 
asymptomatic patients. 4. Genetic testing solely for purposes of proband identification. 5. Genetic testing with 
family history as the only indication. Gene tests for cardiovascular disease are considered germline testing, and 
therefore only permitted once per beneficiarys lifecycle. You can find this guidance in the LCD Genetic 
Testing for Cardiovascular Disease (L39082). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.