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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 many applications of the molecular pathology procedures are not covered services given lack of 
benefit category (e.g., preventive service or screening for a genetic abnormality in the absence of a suspicion of 
disease) and/or failure to the reasonable and necessary threshold for coverage (e.g., based on quality of clinical 
evidence and strength of recommendation or when the results would not reasonably be used in the management 
of a beneficiary). Furthermore, payment of claims in the past (based on stacking codes) or in the future (based 
on the new code series) is not a statement of coverage since the service may not have been audited for 
compliance with program requirements and documentation supporting the reasonable and necessary testing for 
the beneficiary. Certain molecular pathology procedures may be subject to prepayment medical review (records 
requested) and paid claims must be supportable, if selected, for post payment audit by the MAC or other 
contractors. Molecular pathology tests for diseases or conditions that manifest severe signs or symptoms in 
newborns and in early childhood or that result in early death (e.g., Canavan disease) could be subject to 
automatic denials since these tests are not usually relevant to a Medicare beneficiary. 
 
Molecular pathology procedures (Tier1 and Tier 2) may be eligible for coverage when ALL of the following 
criteria are met: 
    a. Alternative laboratory or clinical tests to definitively diagnose the disorder/identify the condition are 
unavailable or results are clearly equivocal; AND 
    b. Availability of a clinically valid test, based on published peer reviewed medical literature; AND 
    c. Testing assay(s) are Food and Drug Administration (FDA) approved/cleared or if LDT (lab developed 
test) or LDT protocol or FDA modified test(s) the laboratory documentation should support assay(s) of 
analytical validity and clinical utility; AND 
    d. Results of the testing must directly impact treatment or management of the Medicare beneficiary; AND 
    e. For testing panels, including but not limited to, multiple genes or multiple conditions, and in cases where a 
tiered approach/method is clinically available, testing would be covered ONLY for the number of genes or test 
that are reasonable and necessary to obtain necessary information for therapeutic decision making; AND     f. Individual has not previously received genetic testing for the disease/condition. (In general, diagnostic 
genetic testing for a disease should be performed once in a lifetime.) Exceptions include clinical scenarios 
whereby repeat testing of somatically acquired mutations (for example, pre- and post- therapy) may be required 
to inform appropriate therapeutic decision-making. 
 
 Limitations: 
 
    Any procedures required prior to cell lysis should be reported separately and utilization must be clearly 
supported based on the application and clinical utility. Such claims may be subject to prepayment medical 
review. 
    The medically necessary interpretation and report of a molecular pathology test, written by a pathologist, 
which is above and beyond the report of standard laboratory results may not be reported by Non- physician 
practitioners (e.g., PhD, scientists etc.); only physicians are eligible to report this service. 
    Testing for quality assurance component of the service is not separately billable. 
 
CFTR (cystic fibrosis transmembrane conductance regulator) (e.g. cystic fibrosis) gene analysis, common 
variants (e.g. ACMG/ACOG guidelines) is considered medically necessary for a beneficiary who has or may 
have cystic fibrosis to guide therapeutic decision-making. 
 
There is a list of individual Tier 2 genetic tests that are unlikely to impact therapeutic decision-making, directly 
impact treatment, outcome and/or clinical management in the care of the beneficiary and will be denied as not 
medically necessary. You can find these rules in the Local Coverage Determination (LCD) Molecular 
Pathology Procedures L35000. 
 
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.