Appeal type: unknown
Decision: unknown

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 following indications for BRCA 1 and BRCA 2 testing are covered by Medicare: 
&#61623; Individual with breast, ovarian1, pancreatic, or prostate cancer from a family with a known deleterious 
BRCA1 or BRCA2 gene mutation. 
&#61623; Individual with a personal history of ovarian1 cancer 
&#61623; Individual with a breast cancer diagnosis meeting any of the following criteria:  
o Diagnosed &#8804;45 y2 
o Triple negative breast cancer (estrogen receptor (ER) negative, progesterone receptor (PR) 
negative, and human epidermal growth factor receptor 2 (HER2) negative) breast cancer 
diagnosed &#8804; 60 y 
o Diagnosed at &#8804; 50 y with:  
&#61607; An additional breast cancer primary 
&#61607; &#8805;1 first, second, or third degree relative5 with breast cancer at any age, or 
&#61607; &#8805;1 first, second, or third degree relative5 with prostate cancer (Gleason score &#8805;7), or 
&#61607; An unknown or limited family history3 
o Breast cancer diagnosed at any age, and  
&#61607; &#8805;1 first, second, or third degree relative5 with breast cancer &#8804;50 y, or 
&#61607; &#8805;1 first, second, or third degree relative5 with ovarian cancer at any age, or 
&#61607; &#8805;1 first, second, or third degree relative5 with metastatic prostate cancer or pancreatic 
cancer at any age 
&#61607; &#8805;2 additional diagnoses of breast cancer at any age in patient and/or in close blood 
relative5, or 
&#61607; A first, second, or third degree male relative with breast cancer 
&#61607; For an individual of ethnicity associated with higher mutation frequency (e.g. Ashkenazi 
Jewish4) no additional family history may be required. 
o Male breast cancer 
&#61623; Personal history of prostate cancer (Gleason score&#8805;7) at any age with: 
o &#8805;1 first, second, or third degree relative5 with ovarian cancer at any age, or 
o &#8805;1 first, second, or third degree relative5 with breast cancer &#8804;50 y, or 
o &#8805;1 first, second, or third degree relative5 with pancreatic cancer at any age, or 
o &#8805;1 first, second, or third degree relative5 with metastatic prostate cancer at any age, or 
o &#8805;2 first, second, or third degree relatives5 with breast cancer and/or pancreatic cancer and/or 
prostate cancer (Gleason score &#8805;7 or metastatic) at any age, or 
o Ashkenazi Jewish ancestry 
&#61623; Personal history of pancreatic cancer at any age 
&#61623; Personal history of metastatic prostate cancer (radiographic evidence of or biopsy-proven disease) 
&#61623; BRCA1/2 pathogenic mutation detected by tumor profiling on any tumor type in the absence of 
germline mutation analysis 
You can find this rule at Local Coverage Determination (LCD): MolDX: BRCA1 and BRCA2 Genetic Testing 
(L36163) (eff. 12/4/19). 
 
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.