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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 Medicare will cover molecular syndromic infectious disease pathogen identification panel 
tests when ALL of the following criteria are met: 
- The patient has a clinical indication for infectious disease testing: 
- The results of testing will impact clinical management in a manner already demonstrated in the peer-reviewed 
published literature to improve patient outcomes. 
- Testing is performed according to the intended use of the test in the intended patient population for which the 
test was developed and validated. 
- An evaluation for more than 1 pathogen by molecular testing is necessary for patient management (testing for 
a single pathogen is NOT reasonable and necessary for the specific infection, patient, or indication). The panel 
performed includes at least the minimum pathogens required for clinical decision making for its intended use 
that can be reasonably detected by the test. 
- Expanded panel testing is only indicated when targeted panel testing is not appropriate (i.e., will not provide 
sufficient information for the appropriate clinical management of the patient). 
- Services that do not have Food and Drug Administration (FDA)-cleared/approved indicated uses, as well as 
FDA-approved tests performed in ways not consistent with their intended-use labeling directions, will require 
registration with Molecular Diagnostic Services Program (MolDX) and a Technical Assessment (TA) to 
demonstrate compliance of the service with this policy. Similarly, tests (and CPT codes) for which there are no 
accompanying ICD-10 codes in the associated Billing and Coding Article will require registration with 
MolDX and a TA to demonstrate compliance of the service with this policy. 
- Documentation of the following is clearly stated in the medical record: 
   - Specific clinical indications for testing (i.e., clinical suspicion of a pathogen as the cause of the patients 
condition) 
   - Specific reasons for performing panel testing 
   - Provider type/specialty and Place of Service 
- Testing must be performed according to Clinical Laboratory Improvement Amendments (CLIA) and/or FDA 
regulations. For example, CLIA-non-waived tests may only be performed in certified laboratories and 
according to CLIA regulations. CLIA-waived tests may be performed in healthcare settings that operate under a CLIA Certificate of Waiver or Certificate of Compliance/Certificate of Accreditation. Panels intended for 
home use (including those that have been FDA approved or cleared) do NOT meet the coverage criteria of this 
policy. 
You can find this information in the Local Coverage Determination (LCD): MolDX: Molecular Syndromic 
Panels for Infectious Disease Pathogen Identification Testing (L39003). 
 
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.