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Decision: unknown

 
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 for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1. 
 
The rules say that pharmacogenetics testing will be considered medically reasonable and necessary if the 
patient has a condition where clinical evaluation has determined the need for a medication that has a known 
gene-drug interaction(s) for which the test results would directly impact the drug management of the patients 
condition; and the test meets evidence standards for genetic testing as evaluated by a scientific, transparent, 
peer-reviewed process and determined to demonstrate actionability in clinical decision making. You can find 
this rule in the Local Coverage Determination for Pharmacogenomics Testing, L39073.  
 
The rules say that genetic testing for hereditary cardiovascular disease will be considered medically reasonable 
and necessary if the patient has rigorous disease-appropriate phenotyping to establish clinical diagnosis or 
suspected diagnosis for which the test results would directly impact the management of the patients condition, 
prior to ordering the test; and the evidence for the gene-disease association is evaluated by the evidence-based, 
transparent, peer-reviewed process of the National Institutes of Health (NIH) sponsored Clinical Genome 
Resource (ClinGen) and is determined to demonstrate actionability in clinical decision making; and clinical 
validity and qualitative descriptors from Moderate, Strong & Definitive with contradictory evidence not being 
reported as disputed or refuted. You can find this rule in the Local Coverage Determination for Genetic Testing 
for Cardiovascular Disease, L39084. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 The rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing 
procedure, the lab shall report only one unit of service of one genomic sequencing procedure, molecular 
multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. 
If no CPT code accurately describes the procedure performed, the lab may report CPT code 81479 with one 
unit of service. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be 
reported for the procedure. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare 
National Correct Coding Initiative Manual, Chapter X(F). 
 
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.