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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 syndromic infectious disease pathogen identification panel tests are covered when 
ALL of the following criteria are met: 
 The patient has a clinical indication for infectious disease testing: 
o For immunocompetent patients, the clinical indication includes a presumption of active infection 
OR infection-associated complications (which may include exacerbation of underlying 
disease) that require the identification of a causative organism for appropriate 
management. Atypical clinical presentations of disease are considered appropriate indications 
for special populations who may not present with classic symptoms of infection (i.e., the 
elderly). 
o For immunocompromised patients (i.e., those with weakened immune systems including those 
with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS), 
patients who are taking immunosuppressive medications (i.e., chemotherapy, biologics, 
transplant-related immunosuppressive drugs, high-dose systemic corticosteroids) and those with 
inherited diseases that affect the immune system (i.e., congenital immunoglobulin deficiencies), 
atypical clinical presentations of disease are considered appropriate indications for testing. In 
this patient population, testing may be performed ONCE as part of a pre-transplant evaluation, 
regardless of the presence of symptoms. 
o Note: For certain panels, such as the Urogenital/Anogenital Panel, epidemiologic indication or 
potential exposure to pathogens as a result of a high-risk experience is considered a covered 
clinical indication, even in the absence of clinical symptoms. These are specifically noted below 
in LIMITED COVERAGE FOR EXPANDED (>5 Pathogens) PANEL TESTING. 
 The results of testing will impact clinical management in a manner already demonstrated in the peer-
reviewed published literature to improve patient outcomes. 
 Testing is performed according to the intended use of the test in the intended patient population for 
which the test was developed and validated. o This includes performing the test using the intended sample types along with parallel testing that 
must accompany the test (i.e., the meningoencephalitis and bloodstream pathogen tests include 
requirements for parallel testing using conventional Gram stain and culture-based detection for 
correlation of results). 
o This also includes the provision - by the laboratory to ordering providers - of the major 
limitations of a given panel test. 
 An evaluation for more than 1 pathogen by molecular testing is necessary for patient management 
(testing for a single pathogen is NOT reasonable and necessary for the specific infection, patient, or 
indication). The panel performed includes at least the minimum pathogens required for clinical decision 
making for its intended use that can be reasonably detected by the test. 
o If additional organisms are not included in a panel, testing for those organisms separately for the 
same indication may be reasonable and necessary in limited circumstances. 
o More than 1 panel may not be performed on the same date of service for the same clinical 
indication, except for bloodstream and meningoencephalitis panels; in such circumstances, a 
second panel may be performed for non-duplicative content. 
You can find this rule at Local Coverage Determination (LCD) L39003: MolDX: Molecular Syndromic Panels 
for Infectious Disease Pathogen Identification Testing (eff. 6/2/22). 
 
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.