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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 provides coverage for multi-gene non-next generation sequencing (NGS) panel 
testing and NGS testing for the diagnostic workup for myeloproliferative disease (MPD), also known as 
myeloproliferative neoplasms (MPNs), and limited coverage for single-gene testing of patients with BCR-ABL 
negative MPD. BCR- ABL negative MPD includes polycythemia vera (PV), essential thrombocythemia (ET), 
and primary myelofibrosis (PMF) 
 A sequential genetic testing approach is expected 
 Once a positive result is obtained and the appropriate diagnosis is established, further testing should stop 
 Reflex testing to the next gene will be considered reasonable and necessary if the following sequence of 
genetic tests produce a negative result: 
1. BCR-ABL negative test results, progress to #2 
2. JAK 2, cv negative test results, progress to #3 or #4 
3. JAK, exon 12 (JAK2 exon 12 is only done when PV is suspected) 
4. CALR/MPL (CALR/MPL is only done when either ET or PMF is suspected; testing for CALR/MPL does 
NOT require a negative JAK2 exon 12, just a negative JAK2 V617F result) 
 Genetic testing of the JAK2 V617F mutation is medically necessary when the following criteria are met: 
o Genetic testing impacts medical management; and 
o Patient would meet World Health Organizations diagnostic criteria for myeloproliferative disease (i.e. 
polycythemia vera, essential thrombocytopenia, primary myelofibrosis) if JAK2 V617F were identified 
 Genetic testing of JAK2 exon 12, performed to identify PV, is medically necessary when the following 
criteria are met: 
o Genetic testing impacts medical management; and 
o Patient would meet World Health Organizations diagnostic criteria for PV, if JAK2 exon 12 testing were 
positive; and 
o JAK2 V617F mutation analysis was previously completed and was negative 
 Genetic testing of the CALR gene (only found in ET and PMF) is medically necessary when the following 
criteria are met: 
o Genetic testing impacts medical management; and 
o JAK2 V617F mutation analysis was previously completed and negative; and 
o Patient would meet World Health Organizations diagnostic criteria for MPD (i.e. ET, PMF) if a clonal 
marker were identified 
 Genetic testing of the MPL gene is medically necessary when the following criteria are met: 
o Genetic testing impacts medical management; and 
o JAK2 V617F mutation analysis was previously completed and negative; and o Patient would meet World Health Organizations diagnostic criteria for MPD (i.e. ET, MPF) if a clonal 
marker were identified 
 Molecular testing for BCR-ABL, JAK 2, JAK, exon 12, and CALR/MPL genes by NGS is covered as 
medically necessary for the identification of myeloproliferative disorders. You can find this information in 
Local Coverage Determination (LCD): Genetic Testing for BCR-ABL Negative Myeloproliferative Disease 
(L36186). 
 
The rules also say that there is non-coverage for genetic testing for thrombophilia testing for the Factor V 
Leiden (FVL) variant in F5 gene, the 20210G>(G20210A) variant in the F2 gene, and the MTHFR gene which 
encodes the 5, 10-methylenetetrahydrofolate reductase enzyme. Genetic testing for these genes for all risk 
factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered 
except for pregnant patients. You can find this information in Local Coverage Determination MolDX: Genetic 
Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) 
(L36400). 
 
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.