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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 are criteria for the BRCA 1 and BRCA 2 testing: 
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 ovarian cancer 
3. Individual with a breast cancer diagnosis meeting any of the following criteria:  
a. Diagnosed 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 with:  
i. An additional breast cancer primary 
ii. greater than or equal to 1 first, second, or third degree relative
5
 with breast cancer at any 
age, or 
iii. greater than or equal to 1 first, second, or third degree relative
5
 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
5
 with breast cancer less 
than or equal to 50 years, or 
ii. greater than or equal to 1 first, second, or third degree relative
5
 with ovarian cancer at 
any age, or 
iii. greater than or equal to 1 first, second, or third degree relative
5
 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
4
) 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
5
 with ovarian cancer at any age, 
or 
b. greater than or equal to 1 first, second, or third degree relative
5
 with breast cancer 50 y, or 
c. greater than or equal to 1 first, second, or third degree relative
5
 with pancreatic cancer at any 
age, or 
d. greater than or equal to 1 first, second, or third degree relative
5
 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.