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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 say that the criteria for BRCA1 and BRCA2 genetic testing are:
 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:
o Diagnosed at age 45 or younger
Triple negative breast cancer (estrogen receptor (ER) negative, progesterone receptor (PR)
negative, and human epidermal growth factor receptor 2 (HER2) negative) breast cancer
diagnosed at age 60 or younger
o Diagnosed at age 50 or younger with:
 An additional breast cancer primary
 1 or more first, second, or third-degree relative(s) with breast cancer at any age, or
 1 or more first, second, or third-degree relative(s) with prostate cancer, or
 An unknown or limited family history
o Breast cancer diagnosed at any age, and
 1 or more first, second, or third-degree relative(s) with breast cancer at age 50 or
younger, or
 1 or more first, second, or third-degree relative(s) with ovarian cancer at any age, or
 1 or more first, second, or third-degree relative(s) with metastatic prostate cancer or
pancreatic cancer at any age
 2 or more additional diagnoses of breast cancer at any age in patient and/or in close
blood relative(s), or
 A first, second, or third-degree male relative with breast cancer
 For an individual of ethnicity associated with higher mutation frequency no additional
family history may be required
o Male breast cancer
 Personal history of prostate cancer at any age with:
o 1 or more first, second, or third-degree relative(s) with ovarian cancer at any age, or
o 1 or more first, second, or third-degree relative(s) with breast cancer age 50 or younger, or
o 1 or more first, second, or third-degree relative(s) with pancreatic cancer at any age, or
o 1 or more first, second, or third-degree relative(s) with metastatic prostate cancer at any age, or
o 2 or more first, second, or third-degree relatives with breast cancer and/or pancreatic cancer
and/or prostate cancer at any age, or
o Ashkenazi Jewish ancestry
 Personal history of pancreatic cancer at any age
 Personal history of metastatic prostate cancer
 BRCA1/2 pathogenic mutation detected by tumor profiling on any tumor type in the absence of
germline mutation analysis
BRCA testing is limited to once-in-a-lifetime. If a patient has been previously tested for BRCA1 and BRCA2,
repeat testing prior to Lynparza therapy is not reasonable and necessary and will not be covered by Medicare.
BRCA1/BRCA2 genetic testing is not reasonable and necessary, thus it is non-covered, for the following
indications:
 Genetic screening in the general population. Such testing is considered screening and is excluded by
Medicare statute.
 Testing of individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal,
pancreatic, or prostate cancer. Such testing is considered screening and is excluded by Medicare statute.
 Testing of individuals under 18 years of age.
You can find these rules in Local Coverage Determination (LCD) 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.