OBJECTIVE
Expanded laboratory panels are tests that can detect six or more pathogens. They result in higher Medicare payments to providers (e.g., hospitals, laboratories, and physicians) than targeted laboratory panels, which are tests that can detect up to five pathogens. There are concerns that providers have been administering expanded laboratory panels when targeted laboratory panels would be sufficient, resulting in significantly higher Medicare payments to those providers. Medicare payments are not allowed for items or services that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member” (Social Security Act § 1862(a)(1)(A)). In addition, some Medicare Administrative Contractors (MACs) have implemented local coverage determinations that include requirements providers must meet to receive Medicare reimbursement for expanded laboratory panels. Our objective is to determine whether Medicare paid providers for selected expanded laboratory panels in accordance with Medicare requirements, including MAC requirements.
TIMELINE
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June 11, 2026Announced