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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 state that the following indications for BRCA 1 and BRCA 2 testing are covered by Medicare: 
 
   - 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 years 
       -- 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 
years 
       -- Diagnosed at less than or equal to 50 years with: 
           - An additional breast cancer primary 
           - greater than or equal to 1 first, second, or third degree relative5 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 or equal to 
50 years, or 
           - 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 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 or equal to 50 
years, 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 rule in the Local Coverage Determination (LCD) for MolDX: BRCA1 and BRCA2 Genetic 
Testing (L36163). 
 
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.