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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 indications for BRCA1 and BRCA2 testing are covered by Medicare: 
61623; Individual with breast, ovarian, pancreatic, or prostate cancer from a family with a known deleterious 
BRCA1 or BRCA2 gene mutation. 
61623; Individual with a personal history of ovarian cancer 
61623; Individual with a breast cancer diagnosis meeting any of the following criteria: 
o Diagnosed at age 45 years or less 
o Triple negative breast cancer breast cancer diagnosed at age 60 years or less 
o Diagnosed ages 46 to 50 years with: 
61607; An additional breast cancer primary 
61607; 1 or more first, second, or third degree relative with breast cancer at any age, or 
61607; 1 or more first, second, or third degree relative with pancreatic cancer at any age, or 
61607; 1 or more first, second, or third degree relative with prostate cancer, or 
61607; An unknown or limited family history 
o Breast Cancer diagnosed at any age 
61607; 1 or more first, second, or third degree relative with breast cancer age 50 years or less, or 
61607; 1 or more first, second, or third degree relative with ovarian cancer at any age, or 
61607; 1 or more first, second, or third degree relative with metastatic prostate cancer or 
pancreatic cancer at any age, or 
61607; 2 or more first, second, or third degree relative with breast cancer and/or pancreatic 
cancer and/or prostate cancer at any age, or 
61607; A first, second, or third degree male relative with breast cancer 
61607; For an individual of ethnicity associated with higher mutation frequency no additional 
family history may be required. 
o Male breast cancer 
61623; Personal history of prostate cancer at any age with: 
o 1 or more first, second, or third degree relative with ovarian cancer at any age, or 
o 1 or more first, second, or third degree relative with breast cancer age 50 years or less, or 
o 1 or more first, second, or third degree relative pancreatic cancer at any age, or 
o 1 or more first, second, or third degree relative with metastatic prostate cancer at any age, or 
o 2 or more first, second, or third degree relative with breast cancer and/or pancreatic cancer 
and/or prostate cancer at any age 
o Ashkenazi Jewish ancestry 
61623; Personal history of metastatic prostate cancer 
61623; Personal history of pancreatic cancer at any age 
61623; 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: 
61623; Genetic screening in the general population. Such testing is considered screening and is excluded by 
Medicare statute. 
61623; Testing of individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, 
pancreatic, or prostate cancer. 
61623; 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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.