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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 plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 1, Section 20.2.
The rules say that specific conditions must be present for coverage of r Next Generation Sequencing. Indications and Limitations of Coverage are listed below: B. Nationally Covered Indications 1. Somatic (Acquired) Cancer Effective for services performed on or after March 16, 2018, the Centers for Medicare & Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following requirements are met: a. Patient has: i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and ii. not been previously tested with the same test using NGS for the same cancer genetic content, and iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). b. The diagnostic laboratory test using NGS must have: i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, ii. an FDA-approved or -cleared indication for use in that patient's cancer; and, iii. results provided to the treating physician for management of the patient using a report template to specify treatment options.
2. Germline (Inherited) Cancer Effective for services performed on or after January 27, 2020, CMS has determined that NGS as a diagnostic laboratory test is reasonable and necessary and covered nationally for patients with germline (inherited) cancer, when performed in a CLIA-certified laboratory, when ordered by a treating physician and when all of the following requirements are met: a. Patient has: i. ovarian or breast cancer; and, ii. a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer; and, iii. a risk factor for germline (inherited) breast or ovarian cancer; and iv. not been previously tested with the same germline test using NGS for the same germline genetic content. b. The diagnostic laboratory test using NGS must have all of the following: i. FDA-approval or clearance; and, ii. results provided to the treating physician for management of the patient using a report template to specify treatment options. C. Nationally Non-Covered Indications 1. Somatic (Acquired) Cancer Effective for services performed on or after March 16, 2018, NGS as a diagnostic laboratory test for patients with acquired (somatic) cancer are non-covered if the cancer patient does not meet the criteria noted in section B.1., above. D. Other 1. Somatic (Acquired) Cancer Effective for services performed on or after March 16, 2018, Medicare Administrative Contractors (MACs) may determine coverage of NGS as a diagnostic laboratory test for patients with advanced cancer only when the test is performed in a CLIA-certified laboratory, when ordered by a treating physician, and when the patient has: a. either recurrent, relapsed, refractory, metastatic, or advanced stages III or IV cancer; and, b. not been previously tested with the same test using NGS for the same cancer genetic content, and c. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 2. Germline (Inherited) Cancer Effective for services performed on or after January 27, 2020, MACs may determine coverage of NGS as a diagnostic laboratory test for patients with germline (inherited) cancer only when the test is performed in a CLIA-certified laboratory, when ordered by a treating physician, when results are provided to the treating physician for management of the patient and when the patient has: a. any cancer diagnosis; and, b. a clinical indication for germline (inherited) testing of hereditary cancers; and, c. a risk factor for germline (inherited) cancer; and, d. not been previously tested with the same germline test using NGS for the same germline genetic content. You can find this in the Medicare National Coverage Determination (NCD) Next Generation Sequencing (90.2).
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. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services.
The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 10 of the Plans 2021 Evidence of Coverage. The Plan contract says that some of the services listed in the Medical Benefits Chart are covered only if your doctor or other network provider gets approval in advance (sometimes called "prior authorization") from us. Covered services that need approval in advance are marked in the Medical Benefits Chart by an asterisk (*). In addition, the following services not listed in the Benefits Chart may require prior authorization: inpatient rehabilitation services, spine surgery, bone growth stimulators, spinal cord stimulators and molecular/genetic testing (for example - screening for cancer). You can find this on page 61 of the Plans 2021 Evidence of Coverage.