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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 the BRCA 1 and BRCA 2 testing: 1. Individual with breast, ovarian, pancreatic, or prostate cancer from a family with a known deleterious BRCA1 or BRCA2 gene mutation. 2. Individual with a personal history of ovarian cancer 3. Individual with a breast cancer diagnosis meeting any of the following criteria: a. Diagnosed less than or equal to 45 years old b. 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 old c. Diagnosed at less than or equal to 50 years with: i. An additional breast cancer primary ii. greater than or equal to 1 first, second, or third degree relative5 with breast cancer at any age, or iii. greater than or equal to 1 first, second, or third degree relative5 with prostate cancer (Gleason score greater than or equal to 7), or iv. An unknown or limited family history d. Breast cancer diagnosed at any age, and i. greater than or equal to 1 first, second, or third degree relative5 with breast cancer less than or equal to 50 years, or ii. greater than or equal to 1 first, second, or third degree relative5 with ovarian cancer at any age, or iii. greater than or equal to 1 first, second, or third degree relative5 with metastatic prostate cancer or pancreatic cancer at any age iv. greater than or equal to 2 additional diagnoses of breast cancer at any age in patient and/or in close blood relative, or v. A first, second, or third degree male relative with breast cancer vi. For an individual of ethnicity associated with higher mutation frequency (e.g. Ashkenazi Jewish4) no additional family history may be required. e. Male breast cancer 4. Personal history of prostate cancer (Gleason score greater than or equal to 7) at any age with:
a. greater than or equal to 1 first, second, or third degree relative5 with ovarian cancer at any age, or b. greater than or equal to 1 first, second, or third degree relative5 with breast cancer &#8804;50 y, or c. greater than or equal to 1 first, second, or third degree relative5 with pancreatic cancer at any age, or d. greater than or equal to 1 first, second, or third degree relative5 with metastatic prostate cancer at any age, or e. 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 f. Ashkenazi Jewish ancestry 5. Personal history of pancreatic cancer at any age 6. Personal history of metastatic prostate cancer (radiographic evidence of or biopsy-proven disease) 7. 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, L36161.
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.