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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. 
 
This policy describes and clarifies coverage for Lab-Developed Tests (LDTs), Federal Drug Administration 
(FDA)-cleared, and FDA-approved clinical laboratory tests in hereditary cancer tests including Next 
Generation Sequencing (NGS) tests as allowable under the National Coverage Determination (NCD) 90.2, 
under section D describing Medicare Administrative Contractor (MAC) discretion for coverage. This policys 
scope is specific for hereditary germline testing, and is exclusive of polygenic risk scores, solid tumor, 
hematologic malignancies, circulating tumor deoxyribonucleic acid (DNA) testing (ctDNA), and other acquired 
cancer-related tests. 
 
All the following must be present for coverage eligibility: 
 The patient must have 
o Any cancer diagnosis 
o AND a clinical indication for germline (inherited) testing for hereditary cancer 
o AND a risk factor for germline (inherited) cancer 
o AND has not been previously tested with the same germline genetic content. 
 The test has satisfactorily completed a Technical Assessment (TA) by Molecular Diagnostic Services 
Program (MolDX

) for the stated indications of the test. 
 The test performed includes at least the minimum genetic content (genes or genetic variants) with 
definitive or well-established guidelines-based evidence required for clinical decision making for its 
intended use that can be reasonably detected by the test. 
o Because these genes and variants will change as the literature and drug indications evolve, they 
are listed separately in associated documents, such as the MolDX TA forms. 
o A single gene or variant may be tested if it is the only gene or variant considered to be 
reasonable and necessary for a cancer type. 
 If a previous test was performed with a similar/duplicative intended use, a subsequent test is only 
reasonable and necessary if the non-duplicative genetic content of the second test is reasonable and 
necessary. 
 If the test is an NGS test, it must abide by all conditions listed in the NCD 90.2. The test in question will be non-covered if: 
 It is an NGS tests and does not fulfill all the criteria set forth in the NCD 90.2 
 A previous test was performed for the same genetic content 
 It is a panel or single gene test used to identify a known familial variant(s) that could be identified with 
a test targeted to that specific variant(s) 
 It is a panel or single gene test used to confirm a variant(s) detected by somatic tumor testing that can 
be confirmed by a test targeted to that specific variant(s) 
 A satisfactory TA is not completed 
 For tests that are currently covered but a TA submission has not been made, providers must submit 
complete TA materials by the original effective date of the policy or coverage will be denied. 
You can find this rule in the Local Coverage Determination (LCD): Lab-Developed Tests for Inherited Cancer 
Syndromes in Patients with Cancer (L38974). 
 
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.