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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 This policy does not designate specific special histochemical stains (aka special stains) 
and/or immunohistochemical (IHC) stains that should be used in the differential diagnosis of tissues or 
neoplasms because this information is readily available in textbooks and various scientific publications. This 
policy identifies the medically necessary criteria for the use of special stains and/or IHC stains and addresses, 
based on claims review, the scenarios that may be driving medically unnecessary over-utilization or incorrect 
billing of these services including: 
 
    Reflex templates or pre-orders for special stains and/or IHC stains prior to review of the routine hematoxylin 
and eosin (H&E) stain by the pathologist; or 
    Use of special stains and/or IHC stains without clinical evidence that the stain is actionable or provides the 
treating physician with information that changes patient management, or 
    Use of added stains when the diagnosis is already known based on morphologic evaluation of the primary 
stain. 
 
It is not reasonable and necessary to perform IHC testing (either single antibody or antibody cocktails) on cases 
with morphologically negative cores. It is not reasonable and necessary to perform IHC testing in a negative or 
a suspicious core biopsy when obvious prostate cancer is present in other cores. While the pathologist may 
choose to confirm a suspicious focus in one or more cores in a case where the diagnosis of cancer has already 
been made, it is not a Medicare covered service because it provides no additional actionable information to the 
treating physician. 
 
Prostate cases that may require reasonable and necessary IHC staining include but are not limited to the 
following: 
 
    Indeterminate/suspicious focus and no other cores are positive for cancer;     Single worrisome core with minimal % tumor (roughly <5%); 
    Worrisome core(s) contralateral to a positive core(s): 
        In a multi-part biopsy with Gleason 3+3=6 cancer in 1 part, and atypical small acinar proliferation (ASAP) 
suspicious for Gleason 3+3=6 cancer in other part(s); the number of positive biopsy sites and % core 
involvement of these sites can affect therapeutic choices for active surveillance (AS), focal therapy or surgery; 
        In a multi-part biopsy with 4+3=7 or 4+4=8 cancer in 1 part, and ASAP suspicious for the same grade 
cancer in other part(s); workup is justified since the extent of high grade cancer affects treatments; 
    Identify tumor invasion of adjacent structures; 
    Determine origin of undifferentiated/poorly differentiated neoplasm, such as bladder vs prostate; 
    Other unexpected results when specific cell stains would be necessary. 
 
Prostate cases when IHC workup is Not Reasonable and Necessary include the following: 
 
    In a multi-part biopsy with =3+4=7 cancer in 1 part, and ASAP suspicious for 3+3=6 cancer in other part(s), 
because stains are unlikely to change treatment; or 
    In a multi-part biopsy with =4+3=7 cancer in 1 part, and "atypical cribriform lesson" (ACL) suspicious for 
intra-ductal carcinoma versus invasive, Gleason pattern 4 cancer in other part(s), because intra-ductal 
carcinoma is almost always closely associated with invasive high-grade cancer. 
 
The International Society of Pathology (ISUP) recommendations state that at the current time, there are no 
prognostic IHC or molecular studies that are recommended to be routinely performed on biopsy or resection 
specimens. 
 
The surgical pathology report is expected to designate the specific block(s) upon which IHC testing is 
performed, the reason for IHC testing, the specific markers, and whether single antibody(ies) or a cocktail of 
antibodies is utilized. A statement alone in the pathology report that states IHC confirms the diagnosis will 
not be covered as reasonable and necessary. 
 
You can find this information in Local Coverage Determination (LCD): Lab: Special Histochemical Stains and 
Immunohistochemical Stains (L36805). 
 
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.