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 state that BRCA1 and BRCA2 genetic testing for susceptibility to breast or ovarian cancer is covered 
in adults as medically reasonable and necessary when there is a personal history of breast cancer (invasive 
breast cancer or ductal carcinoma in situ) and ANY of the following indications: 
- Diagnosed at age 45 or younger; 
- Diagnosed at age 50 or younger with at least one close blood relative* with breast cancer at any age; 
- Diagnosed with two breast primaries (includes bilateral disease or cases where there are two or more 
clearly separate ipsilateral primary tumors) when the first breast cancer diagnosis occurred prior to age 50; 
- Diagnosed at age 60 or younger 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 and there are at least two close blood relatives* with pancreatic cancer or prostate 
cancer with Gleason score >7 at any age; 
- Diagnosed at age 50 or younger with a limited family history (e.g., fewer than two first or second degree 
female relatives or female relatives surviving beyond 45 years in the relevant maternal and/or paternal 
lineage); 
- Diagnosed at any age and there are at least two close blood relatives* with breast cancer at any age; 
- Diagnosed at any age with at least one close blood relative* with breast cancer at age 50 or younger;
- Diagnosed at any age with at least one close blood relative* with epithelial ovarian cancer, fallopian tube, 
or primary peritoneal cancer; 
- Close male blood relative* with breast cancer; 
- Individual of Ashkenazi Jewish descent (begin testing with Ashkenazi Jewish founder specific mutations). 
If negative, complete analysis may be considered if ancestry also includes non-Ashkenazi Jewish relatives 
or other criteria for BRCA1/BRCA2 genetic testing are 
 
You can find these rules in the Local Coverage Determination (LCD) for BRCA1 and BRCA2 Genetic Testing, 
L36499. This LCD is effective for services provided on or after October 1, 2019. 
 
The rules say that screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
CMS 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
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.