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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 testing for carcinoembryonic antigen (CEA) may be medically necessary for follow-up of 
patients with colorectal carcinoma. It would however only be medically necessary at treatment decision-
making points. In some clinical situations (e.g., adenocarcinoma of the lung, small cell carcinoma of the lung, 
and some gastrointestinal carcinomas) when a more specific marker is not expressed by the tumor, CEA may 
be a medically necessary alternative marker for monitoring. Preoperative CEA may also be helpful in 
determining the post-operative adequacy of surgical resection and subsequent medical management. In general, 
a single tumor marker will suffice in following patients with colorectal carcinoma or other malignancies that 
express such tumor markers. You can find this information in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-03, National Coverage Determinations Manual: Carcinoembryonic 
Antigen (190.26). 
 
The rules also say that a CA-125 level may be obtained as part of the initial pre-operative work-up for women 
presenting with a suspicious pelvic mass to be used as a baseline for purposes of post-operative monitoring. 
Initial declines in CA-125 after initial surgery and/or chemotherapy for ovarian carcinoma are also measured 
by obtaining three serum levels during the first month post treatment to determine the patient's CA 125 half-
life, which has significant prognostic implications. 
 
The CA-125 levels are again obtained at the completion of chemotherapy as an index of residual disease. 
Surveillance CA-125 measurements are generally obtained every 3 months for 2 years, every 6 months for the 
next 3 years, and yearly thereafter. CA-125 levels are also an important indicator of a patient's response to 
therapy in the presence of advanced or recurrent disease. In this setting, CA-125 levels may be obtained prior to each treatment cycle. The service may be ordered at times necessary to assess either the presence of 
recurrent disease or the patient's response to treatment with subsequent treatment cycles. The CA-125 is 
specifically not covered for aiding in the differential diagnosis of patients with a pelvic mass as the sensitivity 
and specificity of the test is not sufficient. You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-03, National Coverage Determinations Manual: 
Tumor Antigen by Immunoassay  CA-125 (190.28). 
 
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.