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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 417.414. 
 
  
  The rules state that molecular diagnostic tests that assess a transplanted allograft for rejection status are covered 
when ALL of the following criteria are met: 
1. The test must provide information about at least one of the two following clinical status determinations: 
- active rejection (AR) status 
-Cellular or Antibody-mediated rejection status 
2. The intended use of the test must be: 
-To assist in the evaluation of adequacy of immunosuppression, wherein a non-invasive or minimally invasive 
test can be used in lieu of a tissue biopsy in a patient for whom information from a tissue biopsy would be used 
to make a management decision regarding immunosuppression, OR 
-As a rule-out test for AR in validated populations of patients with clinical suspicion of rejection with a non-
invasive or minimally invasive test to make a clinical decision regarding obtaining a biopsy, OR 
-For further evaluation of allograft status for the probability of allograft rejection after a physician-assessed 
pretest, OR 
-To assess rejection status in patients that have received a biopsy, but the biopsy results are inconclusive or 
limited by insufficient material. 
2. The test demonstrates analytical validity (AV), including an analytical and clinical validation for any given 
measured analytes, and has demonstrated equivalence or superiority for sensitivity or specificity (depending on 
intended use) of detecting allograft rejection to other already-accepted tests for the same intended use 
measuring the same or directly comparable analytes. 
3. Clinical validity (CV) of any analytes (or expression profiles) measured must be established through a study 
published in the peer-reviewed literature for the intended use of the test in the intended population. The degree 
of validity must be similar or superior to established and covered tests (see associated coverage Articles). If 
conducted with concordance to tissue histologic evaluation the Banff Classification for renal allografts or other 
accepted criteria (if existing) for other organs must be used. 
4. The test is being used in a patient who is part of the population in which the test was analytically validated 
and has demonstrated CV. 
5. For a given patient encounter, only one molecular test for assessing allograft status may be performed 
UNLESS a second test, meeting all the criteria established herein, is reasonable and necessary as an adjunct to 
the first test. 
6. For minimally or non-invasive tests, the benefit to risk profile of the molecular test is considered by the 
ordering clinician to be more favorable than the benefit to risk profile of a tissue biopsy, or a tissue biopsy 
cannot be obtained. For example, this may be the case if a biopsy is considered medically contraindicated in a 
patient. 
7. The test successfully completes a Technical Assessment that will ensure that AV, CV, and clinical utility 
criteria set in this policy are met to establish the test as Reasonable and Necessary. 
 
You can find this information in Local Coverage Determination (LCD): MolDX: Molecular Testing for Solid 
Organ Allograft Rejection (L38629). 
 
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.