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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 this is a limited coverage policy for pharmacogenomics testing (PGx) including single gene,
multi-gene panels, and combinatorial tests. These tests are generally covered (with a few exceptions) as
described in further detail below to improve safety in the use of specific medications by avoiding potentially
harmful medications, doses and/or adverse reactions known to occur with certain genotypes.

PGx testing is considered reasonable and necessary in limited circumstances as described below as an
adjunctive personalized medical decision-making tool once a treating clinician has narrowed treatment
possibilities to specific medications under consideration for use, or is already using a specified medication,
based on other clinical considerations including the patient's diagnosis, the patient's other medical conditions,
other medications, professional judgment, clinical science and basic science pertinent to the drug, and the
patient's preferences and values.

PGx tests must demonstrate analytical validity, clinical validity, and clinical utility to be considered reasonable
and necessary for coverage. This is demonstrated through a required technical assessment of the test. PGx tests
are considered germline tests and must adhere to other relevant germline testing policies published by this
contractor.

It is understood that some panel/combinatorial tests may include content that has demonstrated clinical utility
and some that has not. In such circumstances, this contractor may provide coverage for the components of tests
that have demonstrated clinical utility when used in the proper clinical context described below.

Clinical Indications

PGx tests are indicated when medications are being considered for use (or already being administered) that are
medically necessary, appropriate, and approved for use in the patient's condition and are known to have a
gene(s)-drug interaction that has been demonstrated to be clinically actionable as defined by the FDA (PGx
information required for safe drug administration) or Clinical Pharmacogenetic Implementation Consortium
(CPIC) guidelines (category A and B).

The selection of the medications in question must be derived from clinical factors/necessity rather than from a
PGx test. Once the putative therapeutic agents are selected, and those agents are known to have gene-drug
interactions as identified above, then a PGx test may be considered reasonable and necessary when the result of
that test is necessary for the physician's decision-making process regarding safely administering or dosing the
drug.

PGx testing is not considered reasonable and necessary merely on the basis of a patient having a particular
diagnosis. Unless the record reflects that the treating clinician has already considered non-genetic factors to
make a preliminary drug selection, PGx testing is not considered reasonable and necessary.

This LCD does not address (provides neither coverage nor non-coverage criteria) PGx testing for
anticoagulation dosing, which is addressed by the National Coverage Determination (NCD) 90.1.

Coverage information

The clinical record must clearly show the use of or intent to prescribe a drug that has known drug-gene
interactions that require a PGx test to be ordered to define the safe use of that drug in that patient.
If a treating clinician orders a single gene test or a test for a particular allele(s), but as a matter of operational
practicality, the laboratory tests that single gene or allele on a platform that looks for variants in other
genes/alleles as well, that particular test done in that particular instance is considered a single gene/allele test
for coverage purposes. In this scenario the provider may bill for the component of the test that was reasonable
and necessary (in this example, the single gene test).

A multi-gene panel is considered reasonable and necessary if more than one single gene on that panel would be
considered reasonable and necessary for safe use of the medication in question or if multiple drugs are being
considered (each fulfilling the criteria of actionable gene-drug interactions identified above) that have different
relevant genes. Additionally, a gene panel must contain at a minimum all the necessary relevant gene/allele
content required for their indicated use to meet clinical utility requirements. Such minimum criteria are
determined by experts including relevant associations such as the Association for Molecular Pathology and are
considered during the technical assessment. A multi-gene panel is not considered reasonable and necessary if
only a single gene on the panel is considered reasonable and necessary.

If two or more single genes are tested, rather than a multi-gene panel, then the record must reflect that a
clinician individually ordered each gene, and each single gene must individually be reasonable and necessary at
the time they are ordered.

The ordering provider of a PGx test is restricted to providers who have the licensure, qualifications, and
necessary experience/training to both diagnose the condition being treated and also to prescribe medications
(the provider must be able to do both) for the condition either independently or in an arrangement as required
by all the applicable state laws.

Test components that are not reasonable and necessary

Genes not identified as having actionable use are not considered reasonable and necessary. The algorithms
employed in combinatorial testing are also not currently considered reasonable and necessary components of
multi-gene testing.

Technical requirements

The treating clinician receiving the laboratory report must be able to use the genetic information presented to
guide treatment. To accomplish this, the laboratory must clearly report the clinical significance of the resultant
genotype, based on empirical data or validated methodologies, as an annotation or interpretation. For clarity,
the report should document the specific genotype-drug interaction that lead to the resultant interpretation.
A lab may test for a reference allele as a matter of exclusion (e.g. report that a patient has a reference allele
when alternate alleles are not found). However, in such cases, the report must identify which allele is the
reference allele and that the reference allele is reported as a matter of exclusion.

Noncovered Indications

PGx testing is not covered when a treating clinician is not considering treatment with a medication that has an
actionable drug-gene interaction, or when the use of a medication with a drug-gene interaction is not reasonable
and necessary.

Special Documentation Requirements

In order for any of the above services to be covered, the patient's medical record must clearly reflect the
following:

1. The patient has a diagnosis for which pharmacologic therapy is reasonable and necessary, and the 
drug or drugs that the clinician is considering using must be reasonable and necessary for the 
treatment of the patient's diagnosis.
2. The clinician has made an initial personalized decision for the patient based on the patient's 
diagnosis, the patient's other medical conditions, other medications the patient is taking, 
professional judgement, clinical science and basic science pertinent to the drug (e.g. mechanism of 
action, side effects), the patient's past medical history, pertinent family history, and the 
patient's preferences and values.
3. The provider performing the service must have a record of what drug(s) is/are being considered 
and for what indication(s) to ensure the test performed is reasonable and necessary.

You can find this in the Local Coverage Determination (LCD): MolDX: Pharmacogenomics Testing (L38294).

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.