To be eligible for payment as a laboratory/pathology service, the service must be:
(1) Ordered and provided by or under the direction of a physician or other licensed practitioner within the scope of practice as defined by state law;
(2) Provided in a hospital or independent laboratory;
(3) Directly related to the diagnosis and treatment of a medical condition;
(4) Authorized under the laboratory's CLIA certification; and
(5) Considered medically necessary as defined in OAC 317:30-3-1(f) and 317:30-5-20.