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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 genetic testing for hereditary cardiovascular disease will be considered medically reasonable 
and necessary if: 
 
    The patient has rigorous disease-appropriate phenotyping to establish clinical diagnosis or suspected 
diagnosis for which the test results would directly impact the management of the patient's condition, prior to 
ordering the test 
    AND 
    The evidence for the gene-disease association is evaluated by the evidence-based, transparent, peer-reviewed 
process of the National Institutes of Health (NIH) sponsored Clinical Genome Resource (ClinGen) and is 
determined to demonstrate actionability in clinical decision making, meeting all bulleted metrics: 
        Disease severity of sudden death, possible death or major morbidity, modest morbidity 
        Substantial or moderate evidence of a greater than 40 percent likelihood of disease 
        Substantial or moderate evidence of a highly effective or moderately effective intervention 
        The nature of intervention is either low risk/medically acceptable/low intensity intervention or moderately 
acceptable/risk/intensive interventions, 
        AND 
    Clinical validity and qualitative descriptors from Moderate, Strong & Definitive with contradictory evidence 
NOT being reported as disputed or refuted. 
 
Limitations 
 
The following are considered not medically reasonable and necessary: 
 
    A genetic test where either analytical validity, clinical validity, or clinical utility has not been established.     Genetic testing in patients who do not demonstrate the disease-appropriate phenotype of the gene-disease 
association. 
    Genetic testing of asymptomatic patients. 
    Genetic testing solely for purposes of proband identification. 
    Genetic testing with family history as the only indication. 
    Gene tests for cardiovascular disease are considered germline testing, and therefore only permitted once per 
beneficiary's lifecycle. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Genetic Testing for 
Cardiovascular Disease (L39084). 
 
The rules say that Pharmacogenetics testing will be considered medically reasonable and necessary if: 
 
    The patient has a condition where clinical evaluation has determined the need for a medication that has a 
known gene-drug interaction(s) for which the test results would directly impact the drug management of the 
patient's condition; AND 
 
    The test meets evidence standards for genetic testing as evaluated by a scientific, transparent, peer-reviewed 
process and determined to demonstrate actionability in clinical decision making by CPIC guideline level A or 
B1; or is listed in the FDA table of known gene-drug interactions where data support therapeutic 
recommendations or a potential impact on safety or response or the FDA label; 
https://www.fda.gov/drugs/science-and-research-drugs/table-pharmacogenomic-biomarkers-drug-labeling ; 
https://www.fda.gov/medical-devices/precision-medicine/table-pharmacogenetic-associations 
 
Some panel/combinatorial tests may include content that has demonstrated actionability and some that has not. 
In these circumstances, the components of the tests that have demonstrated actionability as noted in #2 will be 
considered medically reasonable and necessary. Refer to the related billing and coding article for coding 
information. 
 
Please refer to National Coverage Determination (NCD) 90.1 for anticoagulation dosing with warfarin. 
 
Limitations 
 
The following is considered not medically reasonable and necessary: 
 
    Genetic testing where either analytical validity, clinical validity, or clinical utility has not been established. 
    Germline testing may be performed once in a lifetime per beneficiary. 
        Any laboratory test that investigates the same germline genetic content, for the same genetic information, 
that has already been tested in the same Medicare beneficiary is not medically reasonable and necessary as it is 
duplicative. The germline sequence of an individual does not change over time, and therefore repeat testing of 
the same germline content for the same genetic information does not provide new clinical information. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Pharmacogenomics Testing 
(L39073). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.