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 criteria for BRCA testing is: 
  
-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 ovarian cancer 
-Individual with a breast cancer diagnosis meeting any of the following criteria: 
  
1. Diagnosed 45 years old or younger 
2. Triple negative breast cancer (estrogen receptor (ER) negative, progesterone receptor (PR) negative, and 
human epidermal growth factor receptor 2 (HER2) negative) breast cancer diagnosed 60 years or younger 
3. Diagnosed at 50 years or younger with: 
  
A. An additional breast cancer primary 
B. 1 or more first, second, or third degree relative5 with breast cancer at any age, or 
C. 1 or more first, second, or third degree relative5 with prostate cancer (Gleason score of 7 or more), or 
D. An unknown or limited family history 
  
4. Breast cancer diagnosed at any age, and 
  
A. 1 first, second, or third degree relative diagnosed with breast cancer 50 years old or younger, or 
B. 1 or more first, second, or third degree relative5 with ovarian cancer at any age, or 
C. 1 or more first, second, or third degree relative5 with metastatic prostate cancer or pancreatic cancer at any 
age 
D. 2 or more additional diagnoses of breast cancer at any age in patient and/or in close blood relative, or 
E. A first, second, or third-degree male relative with breast cancer 
F. For an individual of ethnicity associated with higher mutation frequency (e.g. Ashkenazi Jewish) no 
additional family history may be required. 
  
5. Male breast cancer 
  
-Personal history of prostate cancer (Gleason score 7 or more) at any age with: 
  
1. 1 or more first, second, or third degree relative with ovarian cancer at any age, or 
2. 1 or more first, second, or third degree relative with breast cancer 50 years or younger, or 
3. 1 or more first, second, or third degree relative5 with pancreatic cancer at any age, or 
4. 1 or more first, second, or third degree relative5 with metastatic prostate cancer at any age, or 
5. 2 or more first, second, or third degree relatives5 with breast cancer and/or pancreatic cancer and/or prostate 
cancer (Gleason score =7 or metastatic) at any age, or 
6. 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 Local Coverage Determination (LCD): MolDX: BRCA1 and BRCA2 Genetic Testing 
(L36163) - Effective January 1, 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.