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 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 if one laboratory procedure evaluates multiple genes using a next generation sequencing 
procedure, the lab shall report only one unit of service of one genomic sequencing procedure, molecular 
multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. 
If no CPT code accurately describes the procedure performed, the lab may report CPT code 81479 with one 
unit of service. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be 
reported for the procedure. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare 
National Correct Coding Initiative Manual, Chapter X(F). 
 
The rules say that LIMITED COVERAGE FOR EXPANDED (greater than 5 Pathogens) PANEL TESTING 
FOR THE SPECIFIC PANEL TYPES LISTED BELOW, ALL OF THE 
FOLLOWING ADDITIONAL CRITERIA MUST BE MET: 
 Respiratory (RP) and Pneumonia (PNP) 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: 
 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
 
 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 
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 Local Coverage Determination for Molecular Diagnostics (MolDX): Molecular 
Syndromic Panels for Infectious Disease Pathogen Identification Testing, L38988.  
 
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.