Appeal type: unknown
Decision: unknown

 
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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that Gastrointestinal (GI) Panels will only be covered when targeted testing is not appropriate 
AND according to the following additional criteria:  
1. For immune-competent patients, at least 1 of the following must apply:  
a. Testing is ordered by a clinician specialist in Infectious Diseases or Gastroenterology for a 
patient with severe and established underlying GI pathology (i.e., inflammatory bowel disease 
(IBD), paralytic ileus, radiation therapy to the intestine) AND identification of an infectious 
cause is necessary to determine next steps in patient management. 
b. 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)
3
 as a result of a presumed GI infection AND the 
patient is being treated in an appropriate critical care facility. 
c. The patients clinical indication for GI panel testing is diarrhea, and ALL of the following 
apply:  i. The diarrheal illness MUST be acute or persistent with signs or risk factors for severe 
disease (i.e., fever, bloody diarrhea, dysentery, dehydration, severe abdominal pain) that 
may warrant hospitalization AND/OR 
ii. The diarrheal illness is not resolving after 7 days AND the patient has NOT taken 
laxatives within 24 hours of the test. 
2. For immune-suppressed patients:  
a. Testing is ordered by a clinician specialist in 1 of the following: Infectious Diseases, 
Gastroenterology, Oncology, Transplant OR the patient is being managed in an appropriate 
critical care facility. 
3. 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 Local Coverage Determination (LCD) MolDX: Molecular Syndromic Panels for 
Infectious Disease Pathogen Identification Testing L39003. 
 
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). 
 
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.