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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 Criteria for Testing:
 Individual with breast, ovarian1, pancreatic, or prostate cancer from a family with a known deleterious
BRCA1 or BRCA2 gene mutation.
 Individual with a personal history of ovarian1 cancer
 Individual with a breast cancer diagnosis meeting any of the following criteria:
 Diagnosed less than or equal to 45 y2
 Triple negative breast cancer (estrogen receptor (ER) negative, progesterone receptor (PR) negative, and
human epidermal growth factor receptor 2 (HER2) negative) breast cancer diagnosed less than or equal to 60 y
 Diagnosed at less than or equal to 50 y with:
 An additional breast cancer primary
 greater than or equal to 1 first, second, or third degree relative with breast cancer at any age, or
 greater than or equal to 1 first, second, or third degree relative5 with prostate cancer (Gleason score
greater than or equal to 7), or
 An unknown or limited family history
 Breast cancer diagnosed at any age, and
 greater than or equal to 1 first, second, or third degree relative with breast cancer less than equal to 50
y, or
 greater than or equal to 1 first, second, or third degree relative5 with ovarian cancer at any age, or
 greater than or equal to 1 first, second, or third degree relative with metastatic prostate cancer or
pancreatic cancer at any age
 greater than or equal to 2 additional diagnoses of breast cancer at any age in patient and/or in close
blood relative, or
 A first, second, or third degree male relative with breast cancer
 For an individual of ethnicity associated with higher mutation frequency (e.g. Ashkenazi Jewish) no
additional family history may be required.
 Male breast cancer
 Personal history of prostate cancer (Gleason score greater than or equal to 7) at any age with:
 greater than or equal to 1 first, second, or third degree relative with ovarian cancer at any age, or
 greater than or equal to 1 first, second, or third degree relative with breast cancer less than equal to 50 y, or
 greater than or equal to 1 first, second, or third degree relative with pancreatic cancer at any age, or
 greater than or equal to 1 first, second, or third degree relative with metastatic prostate cancer at any age,
or
 greater than or equal to 2 first, second, or third degree relatives with breast cancer and/or pancreatic
cancer and/or prostate cancer (Gleason score greater than or equal to 7 or metastatic) at any age, or
 Ashkenazi Jewish ancestry
 Personal history of pancreatic cancer at any age
 Personal history of metastatic prostate cancer (radiographic evidence of or biopsy-proven disease)
 BRCA1/2 pathogenic mutation detected by tumor profiling on any tumor type in the absence of germline
mutation analysis
You can find this information in Medicare's Local Coverage Determination (LCD): MolDX: BRCA1 and
BRCA2 Genetic Testing (L36163).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com