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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 that screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
The rules state that pharmacogenomics testing (PGx) tests are indicated when medications are being considered 
for use (or already being administered) that are medically necessary, appropriate, and approved for use in the 
patients condition and are known to have a gene(s)-drug interaction that has been demonstrated to be clinically 
actionable as defined by the FDA (PGx information required for safe drug administration) or Clinical 
Pharmacogenetic Implementation Consortium (CPIC) guidelines. 
 The selection of the medications in question must be derived from clinical factors/necessity rather than from a 
PGx test. Once the putative therapeutic agents are selected, and those agents are known to have gene-drug 
interactions as identified above, then a PGx test may be considered reasonable and necessary when the result of 
that test is necessary for the physicians decision-making process regarding safely administering or dosing the 
drug. 
PGx testing is not considered reasonable and necessary merely on the basis of a patient having a particular 
diagnosis. Unless the record reflects that the treating clinician has already considered non-genetic factors to 
make a preliminary drug selection, PGx testing is not considered reasonable and necessary. 
In order for any of the above services to be covered, the patients medical record must clearly reflect the 
following: 
1. The patient has a diagnosis for which pharmacologic therapy is reasonable and necessary, and the drug 
or drugs that the clinician is considering using must be reasonable and necessary for the treatment of the 
patients diagnosis. 
2. The clinician has made an initial personalized decision for the patient based on the patients diagnosis, 
the patients other medical conditions, other medications the patient is taking, professional judgement, 
clinical science and basic science pertinent to the drug (e.g. mechanism of action, side effects), the 
patients past medical history and when pertinent family history and the patient's preferences and 
values. 
3. The provider performing the service must have a record of what drug(s) is/are being considered and for 
what indication(s) to ensure the test performed is reasonable and necessary. 
Local Coverage Determination (LCD) for MolDX: Pharmacogenomics Testing, L38394 
 
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.