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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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that respiratory panels will only be covered when targeted testing is not appropriate AND 
according to the following additional criteria: 
 For immune-competent patients, at least 1 of the following must apply: 
o Testing is ordered by a clinician specialist in Infectious Diseases or Pulmonology for a patient 
with severe and established underlying respiratory pathology (i.e., severe asthma, chronic 
obstructive pulmonary disease (COPD), cystic fibrosis, pulmonary fibrosis, radiation therapy to 
the lung) AND treatment with antibiotics may be indicated according to established 
guidelines.
1,2
 Specific examples that do NOT meet coverage criteria according to established 
guidelines include the following: 
 Asthma exacerbations without the additional presence of either fever and purulent 
sputum or radiographic evidence of pneumonia
2
 
 Uncomplicated community acquired pneumonia (CAP)
1
 
o The patient is seriously or critically ill or at imminent risk of becoming seriously or critically 
ill (as defined by the American Hospital Associations General Guide for the Release of 
Information on the Condition of Patients) as a result of a presumed respiratory infection AND 
the patient is being treated in an appropriate critical care facility. 
 For immune-suppressed patients: Testing is ordered by a clinician specialist in 1 of the following: 
Infectious Diseases, Pulmonology, Oncology, Transplant OR the patient is being managed in an 
appropriate critical care facility. 
 For ALL patients: Only 1 of the following panels - RP OR PNP- will be covered for a given patient for 
the same clinical indication. The PNP should be prioritized in the evaluation of pneumonia from lower 
respiratory tract specimens (i.e., bronchoalveolar lavage samples [BALs]).  For the purposes of repeat panel testing for the same clinical indication, RP and PNP will be considered 
as equivalent tests, such that if criteria for repeat testing are met (as defined above), a clinician may 
choose to perform the repeat test using the PNP, even if the original test was performed using the RP. 
 For ALL patients, exceptions to the limitation on medical specialists who can order expanded panel 
tests are provided in the accompanying Billing and Coding Article, such that patient geography and 
access to care do not preclude the receipt of appropriate diagnostic testing when indicated. 
 
You can find this rule in the Molecular Diagnostics (MolDX): Molecular Syndromic Panels for Infectious 
Disease Pathogen Identification Testing, L39044. 
 
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.