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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 screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. You can find this rule at 42 CFR Section 411.15(a)(1) and 42 
CFR Section 410.64. 
 
The rules say that this policy describes and clarifies coverage for Lab-Developed Tests (LDTs), Federal Drug 
Administration (FDA)-cleared, and FDA-approved clinical laboratory tests in hereditary cancer tests including 
Next Generation Sequencing (NGS) tests as allowable under the National Coverage Determination (NCD) 
90.2, under section D describing Medicare Administrative Contractor (MAC) discretion for coverage. This 
policys scope is specific for hereditary germline testing, and is exclusive of polygenic risk scores, solid tumor, 
hematologic malignancies, circulating tumor deoxyribonucleic acid (DNA) testing (ctDNA), and other acquired 
cancer-related tests. 
 
Criteria for Coverage 
All the following must be present for coverage eligibility: 
 
    The patient must have 
        Any cancer diagnosis 
        AND a clinical indication for germline (inherited) testing for hereditary cancer 
        AND a risk factor for germline (inherited) cancer 
        AND has not been previously tested with the same germline genetic content. 
    The test has satisfactorily completed a Technical Assessment (TA) by Molecular Diagnostic Services Program (MolDX) for the stated indications of the test. 
     The test performed includes at least the minimum genetic content (genes or genetic variants) with definitive 
or well-established guidelines-based evidence required for clinical decision making for its intended use that can 
be reasonably detected by the test. 
        Because these genes and variants will change as the literature and drug indications evolve, they are listed 
separately in associated documents, such as the MolDX TA forms. 
         A single gene or variant may be tested if it is the only gene or variant considered to be reasonable and 
necessary for a cancer type. 
    If a previous test was performed with a similar/duplicative intended use, a subsequent test is only reasonable 
and necessary if the non-duplicative genetic content of the second test is reasonable and necessary. 
    If the test is an NGS test, it must abide by all conditions listed in the NCD 90.2. 
 
Situations in which a test should not be used or coverage is denied: 
The test in question will be non-covered if: 
 
    It is an NGS test does not fulfill all the criteria set forth in the NCD 90.2 
    A previous test was performed for the same genetic content 
    It is a panel or single gene test used to identify a known familial variant(s) that could be identified with a test 
targeted to that specific variant(s) 
    It is a panel or single gene test used to confirm a variant(s) detected by somatic tumor testing that can be 
confirmed by a test targeted to that specific variant(s) 
    A satisfactory TA is not completed 
    For tests that are currently covered but a TA submission has not been made, providers must submit complete 
TA materials by the original effective date of the policy or coverage will be denied. 
 
An estimated 5-10% of cancers have a heritable component, and there are a growing number of hereditary 
cancer syndromes.1-5 Identifying pathogenic variants in genes associated with hereditary cancer syndromes 
can uncover genomic mechanisms that have predictive, diagnostic, and prognostic utility to patients and are 
used to better their management.6-8 Pathogenic variants in germline genes have been associated with an 
increased lifetime risk of hereditary breast and ovarian (HBOC), colorectal (CRC), as well as other cancers, 
such as endometrial, pancreatic, prostate, and melanoma. Traditionally, testing of genes associated with 
hereditary cancers was performed based on specific gene-disease relationships and an individuals personal or 
family history, often in a single-gene reflex fashion. However, the growing number of genes known to be 
associated with hereditary cancer syndromes and the overlap between clinical presentations has challenged this 
paradigm. You can find these rules in the Local Coverage Determination (LCD) MolDX: Lab-Developed Tests 
for Inherited Cancer Syndromes in Patients with Cancer L38972. 
 
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.