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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 in the case of tests for infectious agents, methodologies include detection by 
immunofluorescence, immunoassay, or nucleic acid probe techniques. A single laboratory procedure shall be 
reported as one unit of service whether it generates one or multiple results. When multiple procedures, multiple 
methodologies, or multiple kits are medically necessary and used to perform a test for multiple infectious 
agents, the units of service reported for codes that identify multiple infectious agents equals the number of 
different procedures, methodologies, or kits used to perform the test. You can find this information in the 
Centers for Medicare & Medicaid Services, Internet Only Manual, National Correct Coding Initiative (NCCI) 
Manual, Chapter 10, Section M(15). 
 
The rules say that respiratory panels will only be covered when targeted testing is not appropriate AND 
according to the following additional criteria: 
 For immune-competent patients, at least 1 of the following must apply: 
 Testing is ordered by a clinician specialist in Infectious Diseases or Pulmonology for a patient 
with severe and established underlying respiratory pathology (i.e., severe asthma, chronic 
obstructive pulmonary disease (COPD), cystic fibrosis, pulmonary fibrosis, radiation therapy to 
the lung) AND treatment with antibiotics may be indicated according to established guidelines. Specific examples that do NOT meet coverage criteria according to established 
guidelines include the following: 
 Asthma exacerbations without the additional presence of either fever and purulent 
sputum or radiographic evidence of pneumonia
2
 
 Uncomplicated community acquired pneumonia (CAP)
1
 
 The patient is seriously or critically ill or at imminent risk of becoming seriously or critically 
ill (as defined by the American Hospital Associations General Guide for the Release of 
Information on the Condition of Patients) as a result of a presumed respiratory infection AND 
the patient is being treated in an appropriate critical care facility. 
 
You can find this rule in the Local Coverage Determination for Molecular Diagnostics (MolDX): Molecular 
Syndromic Panels for Infectious Disease Pathogen Identification Testing, L39003.  
 
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 SARSCoV2 or the 
diagnosis of the virus that causes Covid19, 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.