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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 screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
CMS 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
The following indications for BRCA 1 and BRCA 2 testing are covered by Medicare: 
 
Criteria for 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 ovarian 1* cancer 
    Individual with a breast cancer diagnosis meeting any of the following criteria: 
        Diagnosed equals 45 y 
        Triple negative breast cancer (estrogen receptor (ER) negative, progesterone receptor (PR) negative, and 
human epidermal  growth factor receptor 2 (HER2) negative) breast cancer diagnosed equals 60 y 
        Diagnosed 46-50 y with: 
            An additional breast cancer primary2 
            equals 1 first, second, or third degree relative5 with breast cancer at any age, or 
            equals 1 first, second, or third degree relative5 with pancreatic cancer at any age, or 
            equals 1 first, second, or third degree relative5 with prostate cancer (Gleason score greater than 7 or 
metastatic), or 
            An unknown or limited family history3 
        Breast Cancer diagnosed at any age 
            equals 1 first, second, or third degree relative 5 with breast cancer less than 50 y, or 
            equals 1 first, second, or third degree relative 5 with ovarian cancer at any age, or 
            equals 1 first, second, or third degree relative 5 with metastatic prostate cancer or pancreatic cancer at 
any age, or 
            equals 2 first, second, or third degree relative5 with breast cancer and/or pancreatic cancer and/or 
prostate cancer (Gleason score greater than 7 or metastatic) at any age, 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. 
        Male breast cancer 
    Personal history of prostate cancer (Gleason score greater than 7 or metastatic) at any age with: 
        equals 1 first, second, or third degree relative 5 with ovarian cancer at any age, or 
        equals 1 first, second, or third degree relative 5 with breast cancer less than 50 y, or 
        equals 1 first, second, or third degree relative 5 pancreatic cancer at any age, or 
        equals 1 first, second, or third degree relative 5 with metastatic prostate cancer at any age, or 
        equals 2 first, second, or third degree relative 5 with breast cancer and/or pancreatic cancer and/or prostate 
cancer (Gleason score greater than 7 or metastatic) at any age 
        Ashkenazi Jewish ancestry 
    Personal history of metastatic prostate cancer (radiographic evidence of a biopsy-proven disease) 
    Personal history of pancreatic cancer at any age 
    BRCA1/2 pathogenic mutation detected by tumor profiling on any tumor type in the absence of germline 
mutation analysis 
 
Limitations 
 
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. 
 
Nationally Non-Covered Indications 
 
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. An ABN must be obtained for BRCA 1 and BRCA 2 testing for individuals without signs and 
symptoms of breast, ovarian or other hereditary cancer syndromes as indicated in this policy. 
    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. An 
ABN must be obtained for BRCA 1 and BRCA 2 testing for individuals without signs and symptoms of breast, 
ovarian or other hereditary cancer syndromes as indicated in this policy 
    Testing of individuals under 18 years of age. 
 
You can find these rules in Local Coverage Determination (LCD) MolDX: BRCA1 and BRCA2 Genetic 
Testing (L36456). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.