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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 BRCA 1 and BRCA 2 testing are covered by Medicare:
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 ovarian1 cancer
3. Individual with a breast cancer diagnosis meeting any of the following criteria:
a. Diagnosed at 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 old with:
i. An additional breast cancer primary
ii. Greater than or equal to 1 first, second, or third degree relative with breast cancer at any age, or
iii. Greater than or equal to 1 first, second, or third degree relative 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 relative with breast cancer less than or equal to 50 years old, or
ii. Greater than or equal to 1 first, second, or third degree relative with ovarian cancer at any age, or
iii. Greater than or equal to 1 first, second, or third degree relative 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 Jewish) 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 relative with ovarian cancer at any age, or
b. Greater than or equal to 1 first, second, or third degree relative5 with breast cancer less than or
equal to 50 years old, or
c. Greater than or equal to 1 first, second, or third degree relative with pancreatic cancer at any
age, or
d. Greater than or equal to 1 first, second, or third degree relative 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.