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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 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 state that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be 
ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or 
treats a beneficiary for a specific medical problem and who uses the results in the management of the 
beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are 
not reasonable and necessary. You can find this information in the 42 CFR  410.32. 
The rules say that the following are considered not medically reasonable and necessary: 
1. Any procedures required prior to cell lysis (e.g., microdissection) 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.  
2. For testing for quality assurance please refer to NCCI Policy Manual for Medicare Services, Chapter 
10, Pathology/Laboratory Services. 
3. Screening services such as pre-symptomatic genetic tests and services used to detect an undiagnosed 
disease or disease predisposition are not a benefit and are not covered. Similarly, the costs of 
tests/examinations that assess the risk of a condition unless the risk assessment clearly and directly 
effects the management of the patient may not be reimbursed. 
4. A specific genetic test may only be performed once in a lifetime per beneficiary for inherited 
conditions; however, when medically reasonable and necessary, genetic testing may be done on 
acquired conditions such as malignancies (including separate malignancies developing at different 
times) as they are treated and are being followed, in order to assess response or other relevant clinical criteria. Likewise, there are situations where medical record and literature documentation are able to 
demonstrate that serial testing can be reasonably predicted to provide additional clinically useful 
information. When the record documents that this information, such as confirmed significant response 
to current therapy, is likely to assist in modifying treatment, serial testing can be considered reasonable 
and necessary and eligible for coverage. 
You can find this information in Local Coverage Determination (LCD) Molecular Pathology Procedures 
L34519. 
 
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.