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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 the patient must have a personal history of breast or ovarian cancer. Testing of unaffected individuals or family member is not a covered Medicare service therefore the National Comprehensive Cancer Network (NCCN) risk evaluation that is performed must be applied to patients with the diagnosis confirmed of cancer of ovarian or breast origin if payment is to be considered. This risk evaluation that follows is performed to determine if a formal risk assessment is necessary. NCCN criteria for further genetic risk evaluation include: 1. An individual with ovarian cancer 2. An individual of Ashkenazi Jewish descent with breast cancer, ovarian cancer, or pancreatic cancer at any age 3. An individual with a personal or family history of three or more of the following (especially if early onset and can include multiple primary cancers in same individual): -breast cancer, -pancreatic cancer, -prostate cancer (Gleason score greater than or equal to 7), -melanoma, -sarcoma, -adrenocortical carcinoma, -brain tumors, -leukemia, -diffuse gastric cancer, -colon cancer, -endometrial cancer, -thyroid cancer, -kidney cancer, -dermatologic manifestations or macrocephaly, -hamartomatous polyps of gastrointestinal (GI) tract 4. An individual with a breast cancer diagnosis meeting any of the following: -A known mutation in a cancer susceptibility gene within the family -Early-age-onset breast cancer -Triple negative (ER-, PR-, HER2-) breast cancer diagnosed at 60 years of age or less -Two primary breast cancer primaries in a single individual -Male breast cancer -Breast cancer at any age and a. greater than or equal to 1 close blood relative** with breast cancer at 50 years of age or less, or b. greater than or equal to 1 close blood relative** with invasive ovarian* cancer at any age, or c. greater than or equal to 2 close blood relatives** with breast cancer or pancreatic cancer at any age, or d. From a population at increased risk 5. An individual with a personal history of cancer with one or more of the following: -A close relative with any of the following: a. A known mutation in a cancer susceptibility gene within the family b. greater than or equal to 2 breast cancer primaries in a single individual c. greater than or equal to 2 individuals with breast cancer primaries on the same side of family with at least one diagnosed at 50 years of age or less d. Ovarian cancer e. Male breast cancer
-First- or second-degree relative with breast cancer at 45 years of age or less -Family history of three or more of the following (especially if early onset and can include multiple primary cancers in same individual) -breast cancer, -pancreatic cancer, -prostate cancer (Gleason score greater than or equal to 7), -melanoma, -sarcoma, -adrenocortical carcinoma, -brain tumors, -leukemia, -diffuse gastric cancer, -colon cancer, -endometrial cancer, -thyroid cancer, -kidney cancer, -dermatologic manifestations or macrocephaly, -hamartomatous polyps of gastrointestinal (GI) tract You can find this rule in the Local Coverage Determination (LCD) - BRCA 1 and BRCA2 Genetic Testing (L36715) - Effective December 10, 2020. The rules say that BRCA 1 and BRCA 2 testing consists of full sequence and duplication/deletion analysis. Genetic testing for a known mutation in a family may be limited to the known familial variant. You can find this rule in the Local Coverage Determination (LCD) - BRCA 1 and BRCA2 Genetic Testing (L36715) - Effective December 10, 2020. The rules say that the following indications for BRCA 1 and BRCA 2 testing are covered by Medicare: Personal history of breast, ovarian, pancreatic or prostate cancer with the following RISK Assessment (stratification) items (1-8 below) that are to be considered before testing in those patients with one of the four mentioned cancers that is suspected to be of hereditary origin. 1. Personal history of ovarian carcinoma 2. Personal history of male breast cancer 3. Individual from a family with a known deleterious BRCA1/BRCA2 gene pathogenic mutation 4. Personal history of breast cancer and one or more of the following indications: -Diagnosed at 45 years of age or less -Diagnosed at 50 years of age or less with: a. An additional breast cancer primary at any age; b. at least 1 close blood relative with breast cancer at any age; c. An unknown or limited family history; -Diagnosed at 60 years of age or less with a triple negative breast cancer (estrogen receptor [ER] negative, progesterone receptor [PR] negative, and human epidermal growth factor receptor 2 [HER2] negative) -Diagnosed at any age with: a. at least 1 close blood relative with breast cancer diagnosed at 50 years of age or less; or
b. at least 1 close blood relative** with ovarian* cancer; or c. at least 1 close blood relative** with pancreatic cancer; or d. at least 1 close blood relative** with prostate cancer (Gleason score greater than or equal to 7 or metastatic); or e. at least 1 close male blood relative** with breast cancer; or f. at least 2 additional diagnoses of breast cancer in patient and/or in close blood relative(s) at any age; -Individual of ethnicity associated with higher pathogenic mutation frequency (e.g. Ashkenazi Jewish) 5. Personal history of pancreatic cancer 6. Personal history of prostate cancer (Gleason score greater than or equal to 7) at any age with: -at least 1 close blood relative with ovarian cancer, pancreatic cancer, or metastatic prostate cancer at any age or breast cancer (at 50 years of age or less); or -at least 2 close blood relatives with breast cancer, or prostate cancer (any grade) at any age; or -Ashkenazi Jewish ancestry 7. Personal history of metastatic prostate cancer 8. BRCA1/2 pathogenic mutation detected by tumor profiling on any tumor type in the absence of germline pathogenic mutation analysis 9. Personal history of cancer types listed above with a family history only (significant limitations of interpreting test results for an unaffected individual exists and therefore are not a covered benefit) -First or second degree blood relative meeting any of the above criteria -Third-degree blood relative who has breast cancer or ovarian carcinoma and who has at least 2 close blood relatives with breast cancer (at least one with breast cancer at 50 years of age or less) or ovarian* carcinoma You can find this rule in Local Coverage Determination (LCD): BRCA1 and BRCA2 Genetic Testing (L36715) - Effective December 10, 2020. The rules say that the NCCN defines close or blood relative as first- (parents, siblings and children), second- (grandparents, aunts, uncles, nieces and nephews, grandchildren and half-siblings), and third degree-relatives (great-grandparents, great-aunts, great uncles, great grandchildren and first cousins) on same side (either maternal or paternal) of the family. You can find this rule in Local Coverage Determination (LCD): BRCA1 and BRCA2 Genetic Testing (L36715) - Effective December 10, 2020.
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.