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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 BRCA1 and BRCA2 genetic testing for susceptibility to breast or ovarian cancer is covered
in adults as medically reasonable and necessary when there is a personal history of breast cancer (invasive
breast cancer or ductal carcinoma in situ) and ANY of the following indications:
1. Diagnosed at age 45 or younger;
2. Diagnosed at age 50 or younger with at least one close blood relative with breast cancer at any age;
3. Diagnosed with two breast primaries (includes bilateral disease or cases where there are two or more clearly
separate ipsilateral primary tumors) when the first breast cancer diagnosis occurred prior to age 50;
4. Diagnosed at age 60 or younger with a triple negative breast cancer (estrogen receptor [ER] negative,
progesterone receptor [PR] negative, and human epidermal growth factor receptor 2 [HER2] negative);
5. Diagnosed at any age and there are at least two close blood relatives with pancreatic cancer or prostate
cancer with Gleason score of more than 7 at any age;
6. Diagnosed at age 50 or younger with a limited family history (e.g., fewer than two first- or second-degree
female relatives or female relatives surviving beyond 45 years in the relevant maternal and/or paternal lineage);
7. Diagnosed at any age and there are at least two close blood relatives with breast cancer at any age;
8. Diagnosed at any age with at least one close blood relative* with breast cancer at age 50 or younger;
9. Diagnosed at any age with at least one close blood relative* with epithelial ovarian cancer, fallopian tube, or
primary peritoneal cancer;
10. Close male blood relative with breast cancer;
11. Individual of Ashkenazi Jewish descent (begin testing with Ashkenazi Jewish founder specific mutations).
If negative, complete analysis may be considered if ancestry also includes non-Ashkenazi Jewish relatives or
other criteria for BRCA1/BRCA2 genetic testing are met.
You can find this rule in Local Coverage Determination (LCD): BRCA1 and BRCA2 Genetic Testing
(L36499) - Effective December 10, 2020.
The rules say that BRCA1 and BRCA2 genetic testing for susceptibility to breast or ovarian cancer is covered
in adults as medically necessary when there is a personal history of ANY of the following indications:
1. Personal history of epithelial ovarian, fallopian tube, or primary peritoneal cancer;
2. Personal history of male breast cancer;
3. Personal history of pancreatic cancer or prostate cancer with Gleason score =7 at any age, =1 close blood
relatives* with breast (=50 y), invasive ovarian, pancreatic cancer, or prostate cancer with Gleason score =7 at
any age;
4. Personal history of pancreatic cancer at any age with Ashkenazi Jewish ancestry (Begin testing with
Ashkenazi Jewish founder specific mutations). If negative, complete analysis should be performed. Complete
analysis may be considered if ancestry also includes non-Ashkenazi Jewish relatives and other criteria for
BRCA1/BRCA2 genetic testing are met.
You can find this rule in Local Coverage Determination (LCD): BRCA1 and BRCA2 Genetic Testing
(L36499) - Effective December 10, 2020.
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.