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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 the date of service (DOS) policy for either a clinical laboratory test or the technical component of 
physician pathology service is as follows: 
 
General Rule: The DOS of the test/service must be the date the specimen was collected. 
 
Variation: If a specimen is collected over a period that spans two calendar days, then the DOS must be the date 
the collection ended. 
 
Exceptions: The following three exceptions apply to the DOS policy for either a clinical laboratory test or the 
technical component of physician pathology service: 
 
A. DOS for Tests/Services Performed on Stored Specimens: 
In this case of a test/service performed on a stored specimen, if a specimen was stored for less than or equal to 
30 calendar days from the date it was collected, the DOS of the test/service must be the date the test/service 
was performed only: 
 
1. The test/service is ordered by the patients physician at least 14 days following the date of the 
patients discharge from the hospital 
2. The specimen was collected while the patient was undergoing a hospital surgical procedure 
3. It would be medically inappropriate to have collected the sample other than during the hospital 
procedure for which the patient was admitted 
4. The results of the test/service do not guide treatment provided during the hospital stay 
5. The test/service was reasonable and medically necessary for treatment of an illness 
 
If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have 
been archived and the DOS of the test/service must be the date the specimen was obtained from storage. 
 
B. DOS for Chemotherapy Sensitivity Tests/Service Performed on Live Tissue: 
In the case of a chemotherapy sensitivity test/service performed on live tissue, the DOS of the test/service must 
be the date the test/service was performed only if: 
1. The decision regarding the specific chemotherapeutic agents to test is made at least 14 days after 
discharge 
2. The specimen was collected while the patient was undergoing a hospital surgical procedure  
3. It would be medically inappropriate to have collected the sample other than during the hospital 
procedure for which the patient was admitted  
4. The results of the test/service do not guide treatment provided during the hospital stay 
5. The test/service was reasonable and medically necessary for treatment of an illness 
 
For purposes of applying the above exception, a chemotherapy sensitivity test is defined as a test that 
requires a fresh tissue sample to test the sensitivity of tumor cells to various chemotherapeutic agents. CMS 
identifies such tests through program instructions issued to the Medicare Administrative Contractors (MACs). 
 
C. DOS for Advanced Diagnostic Laboratory Tests and Molecular Pathology Tests: 
In the case of molecular pathology test performed by a laboratory other than a blood bank or center, or a test 
designated by CMS as an ADLT under paragraph (1) of the definition of advanced diagnostic laboratory test in 
42 CFR 414.502, the DOS must be the date the test was performed only if: 
 
1. The test was performed following a hospital outpatients discharge from the hospital outpatient 
department 
2. The specimen was collected from a hospital outpatient during an encounter 3. It was medically appropriate to have collected the sample from the hospital outpatient during the 
hospital outpatient encounter 
4. The results of the test do not guide treatment provided during the hospital outpatient encounter 
5. The test was reasonable and medically necessary for the treatment of an illness 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 16, Section 40.8. 
 
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.