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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 are criteria for BRCA1/BRCA 2 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 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 
o Diagnosed at 46-50 y 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 history3 
o Breast cancer diagnosed at any age, and  
; Greater than or equal to 1 first, second, or third degree relative5 with breast cancer &#8804;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 relative5 with metastatic prostate 
cancer or pancreatic cancer at any age, or 
; 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 
Jewish4) no additional family history may be required. 
o Male breast cancer 
? Personal history of prostate cancer (Gleason score greater than or equal to 7) at any age with: 
o Greater than or equal to 1 first, second, or third degree relative with ovarian cancer at any age, 
or 
o Greater than or equal to 1 first, second, or third degree relative with breast cancer less than or 
equal to 50 y, or 
o Greater than or equal to 1 first, second, or third degree relative pancreatic cancer at any age, or 
o Greater than or equal to 1 first, second, or third degree relative with metastatic prostate cancer at 
any age, or 
o Greater than or equal to 2 first, second, or third degree relatives with breast cancer and/or 
pancreatic cancer and/or prostate cancer (any grade) 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 these rules in the Local Coverage Determination (LCD) for MolDX: BRCA1 and BRCA2 
Genetic Testing, L36082. This LCD is effective for services provided on or after December 4, 2019. 
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.