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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 any test that involves the detection or identification of nucleic acid(s) (DNA/RNA), proteins, 
chromosomes, enzymes, cancer chemotherapy sensitivity and/or other metabolite(s). The test may or may not 
include multiple components. A MDT may consist of a single mutation analysis/identification, and/or may or 
may not rely upon an algorithm or other form of data evaluation/derivation. Laboratory developed test (LDT): 
Any test developed by a laboratory developed without Food and Drug Administration (FDA) approval or 
clearance. 
 
Applicable Tests/Assays 
 
In addition to the MDT definition, this coverage policy applies to all tests that meet at least one of the 
following descriptions: 
 All non-FDA approved/cleared laboratory developed tests (LDT) 
 All modified FDA-approved/cleared kits/tests/assays 
 All tests/assays billed with more than one code from a HIPAA compliant code set to identify the service, 
including combinations of method-based, serology-based, and anatomic pathology codes 
 All tests that meet the first three bullets and are billed with a Not Otherwise Classified NOC code 
  
Unique Test Identifier Requirement 
 
Because the available language in the current HIPAA compliant code sets used to describe the pathology and 
laboratory categories and the tests included in those categories are not specific to the actual test results 
provided, all MDT services must include an identifier as additional claim documentation. Test providers must 
receive an identifier specific to the applicable test and submit the test assigned identifier with the claim for 
reimbursement. The assigned identifier will provide a crosswalk between the tests associated detail 
information on file and the submitted claim detail line(s) required to adjudicate each tests claim. The unique 
identifier limits the need to submit the required additional information about the test on each claim. 
 
Technology Assessments (TA) 
 
MolDX will review all new test/assay clinical information to determine if a test meets Medicares reasonable 
and necessary requirement. Labs must submit a comprehensive dossier on each new test/assay prior to claim 
submission. MolDX will only cover and reimburse tests that demonstrate analytical and clinical validity, and 
clinical utility at a level that meets the Medicare reasonable and necessary requirement. Payment Rules 
 
MolDX will reimburse: 
 approved tests covered for dates of service consistent with the effective date of the coverage determination. 
 
Covered Tests 
 
Please refer to the Noridian website for specific coding and billing information for services addressed in 
MolDX. 
 
Other tests/assays may be addressed by separate Noridian policy. In addition, the CPT codes listed under 
Group 1 are addressed in the MolDX program. If a test is not linked below under Related Local Coverage 
Documents, it may be addressed under separate Noridian policy, or it has not been approved for coverage as it 
has either not been vetted by the MolDx contractor or has been found to be considered statutorily excluded. 
 
You can find these rules in the Local Coverage Determination (LCD) MolDX: Molecular Diagnostic Tests 
(MDT) L35160. 
 
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.