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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 is a limited coverage policy for molecular biomarker tests to guide targeted therapy 
selection in Rheumatoid Arthritis (RA). 
The following are the coverage criteria: 
1. The patient is an adult with a confirmed diagnosis of moderately to severely active RA. 
2. The patient has a history of failure, contraindication, or intolerance to at least one first-line therapy for 
the treatment of RA (i.e., conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs)) 
despite adequate dosing. 
3. The patient has not initiated a biologic or targeted synthetic therapy (b/tDMARD) for RA (i.e., Tumor 
Necrosis Factor- inhibitor [TNFi], Janus Kinase [JAK] inhibitor, etc.) OR has initiated b/tDMARD 
therapy and is being considered for an alternate class of targeted therapies as a result of failure, 
contraindication, or intolerance to the initial targeted therapy despite adequate dosing. 
4. The test predicts response and/or non-response to at least one class of targeted or biologic therapies for 
RA according to multiple validated response/remission criteria (a) with an accuracy that exceeds that 
which can be obtained from the combination of existing clinical and other data AND (b) with 
demonstrated reproducibility across clinical study cohorts. 
5. Testing using molecular biomarkers has not been previously performed for predictive therapy selection 
in RA. 
6. Testing is performed according to the intended use of the test in the intended patient population for 
which the test was developed and validated. 
7. The test demonstrates analytical validity (AV), clinical validity (CV) and clinical utility (CU), 
establishing a clear and significant biological/molecular basis for stratifying patients and subsequently 
selecting (either positively or negatively) a clinical management in a clearly defined population. 8. Clinical validity of any analytes (or expression profiles) measured must be established through a study 
published in the peer-reviewed published literature for the intended use of the test in the intended 
population. 
9. If the test relies on an algorithm, the algorithm must be validated in a cohort that is not a development 
cohort for the algorithm. 
10. The lab providing the test is responsible for clearly indicating to treating physicians the population and 
indication(s) for test use. 
11. The test successfully completes a Molecular Diagnostic Services Program (MolDX) Technical 
Assessment that ensures that AV, CV, and CU criteria set in this policy are met to establish the test as 
Reasonable and Necessary. 
12. If applicable, performance characteristics are equivalent or superior to the average performance of other 
similar tests (for the same intended use) evaluated by this contractor upon successful completion of a 
technical assessment. 

You can find this rule in the Local Coverage Determination (LCD) 
MolDX: Molecular Biomarker Testing to Guide Targeted Therapy Selection in Rheumatoid Arthritis, L39481. 
 
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.