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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 Molecular cytogenetic testing FISH may be utilized to address specific, focused clinical 
questions and is available for a variety of clinical application including the assessment of both constitutional 
and acquired chromosomal aberrations. FISH testing is a method by which an assessment is made for the 
presence, absence, relative position and/or copy number of specific DNA segments by fluorescence 
microscopy. FISH involves hybridization of a fluorochrome-labeled DNA probe to an in situ chromosomal 
target. Metaphase preparations from cultured cells that are routinely used for cytogenetic analysis are 
considered the gold standard because morphology and position of the fluorescent signals can be visualized 
directly. A major advantage of FISH is that it can be performed on non-dividing interphase cells, affording a 
rapid screen for specific chromosome rearrangements or numerical abnormalities associated with hematologic 
malignancies. Interphase analysis can be performed on bone marrow cell suspensions routinely used for 
conventional cytogenetics, paraffin-embedded tissue sections, or disaggregated cells from paraffin blocks, bone 
marrow, blood smears and touch-preparations of cells from lymph nodes or solid tumors. 
 
The majority of probes used for clinical FISH testing are considered analyte-specific reagents, i.e., reagents that 
are produced under good manufacturing practice guidelines set forth by the Federal Drug Administration 
(FDA), but their safety and efficacy must be established by the user. When a new analyte-specific reagent 
probe is introduced in the lab, specific validation of the probe itself (probe validation) and validation of the 
procedures using the probe (analytical validation) is needed. Known normal and abnormal cases are used to 
validate a FISH test. A variety of FISH probes are available: 
 
    Enumeration probes (e.g., 1 color chromosome 8 a-satellite centromere probe; 2 color X/Y probes) 
    Dual-color, dual-fusion probes (e.g., BCR/ABL1; IGH/BCL2; PML/RARA) 
    Single-fusion, extra signal (ES) probes (e.g., ETV6/RUNX1; BCR/ABL1 ES) 
    Break-apart probes (e.g., CBFB, MLL) 
 
FISH testing is indicated in the evaluation of patients whose bone marrow examination is suggestive of MDS 
and who have had a failed or inadequate cytogenetic assessment (conventional karyotype). 
 
Limitations 
 
    When the results of conventional cytogenetics are adequate, FISH testing is not reasonable and necessary 
and not a Medicare benefit. 
    When conventional karyotyping is inadequate, Medicare will limit initial FISH testing to 4 probes (studies) as specified above in this policy. 
    Reflex FISH testing may be indicated when the initial 4 probes are negative. 
    Molecular Next Generation Sequence (NGS) testing alone (for myeloid mutations) or in combination with 
FISH testing is not reasonable and necessary for the diagnosis of MDS, and is not a Medicare benefit; 
    When a patient has a bone marrow suggestive of another disorder (e.g., a plasma cell disorder), MDS-FISH 
is not indicated; 
    Delay in diagnosis is not a legitimate reason for performing more than 4 initial FISH studies followed by 
step-wise reflex testing; 
    Repeat FISH testing by another laboratory on the same specimen is not reasonable and necessary. 
 
You can find these rules in the Local Coverage Determination (LCD) MDS FISH L37622. 
 
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.