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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. You can find this rule at 42 CFR Section
411.15(a)(1) and 42 CFR Section 410.64.
The following indications for BRCA1 and BRCA2 testing are covered by Medicare for an 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 ovarian1* cancer
- Individual with a breast cancer diagnosis meeting any of the following criteria:
o Diagnosed 45 y
o Triple negative breast cancer (estrogen receptor (ER) negative, progesterone receptor (PR)
negative, and human epidermal growth factor receptor 2 (HER2) negative) breast cancer
diagnosed  60 y
o Diagnosed at 46-50 y with:
 An additional breast cancer primary
 1 first, second, or third degree relative5 with breast cancer at any age, or
 1 first, second, or third degree relative5 with prostate cancer (Gleason score 7), or
 An unknown or limited family history3
o Breast cancer diagnosed at any age, and
 1 first, second, or third degree relative5 with breast cancer 50 y, or
 1 first, second, or third degree relative5 with ovarian cancer at any age, or
 1 first, second, or third degree relative5 with metastatic prostate cancer or pancreatic
cancer at any age, or
 2 additional diagnoses of breast cancer at any age in patient and/or in close blood
relative5, 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.
o Male breast cancer
- Personal history of prostate cancer (Gleason score7) at any age with:
o 1 first, second, or third degree relative5 with ovarian cancer at any age, or
o 1 first, second, or third degree relative5 with breast cancer 50 y, or
o 1 first, second, or third degree relative5 pancreatic cancer at any age, or
o 1 first, second, or third degree relative5 with metastatic prostate cancer at any age, or
o 2 first, second, or third degree relatives5 with breast cancer and/or pancreatic cancer and/or
prostate cancer (any grad) at any age, or
o Ashkenazi Jewish ancestry
- Personal history of pancreatic cancer at any age
- Personal history of metastatic prostate cancer (radiographic evidence of or biopsy-proven disease)
- BRCA1/2 pathogenic mutation detected by tumor profiling on any tumor type in the absence of
germline mutation analysis
1Includes fallopian tube and primary peritoneal cancers. BRCA - related ovarian cancers are associated with
epithelial, non-mucinous histology.
2Two breast cancer primaries include bilateral (contralateral) disease or 2 or more clearly separate ipsilateral
primary tumors either synchronously or asynchronously.
3Medicare will cover BRCA-testing for an adopted individual with breast cancer diagnosed 50 y, that is
suspicious of being a BRCA-related cancer. Individuals with limited family history/structure, defined as fewer
than 2 females first- or second-degree relatives having lived beyond age 45 in either lineage may also be
eligible for BRCA gene testing. Similar to all testing, these situations require explanation of medical necessity
for BRCA testing in the patient's medical record, and documentation of genetic counseling prior to BRCA
testing.
4Testing for Ashkenazi Jewish founder-specific mutations should be performed first. Comprehensive BRCA1/2
testing may be considered if ancestry also includes non-Ashkenazi Jewish relatives or if any of the other
BRCA-related criteria are met.
You can find these rules in the Medical Local Coverage Determination (LCD) MoIDX: BRCA1 and BRCA2
Genetic Testing (L36163).
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.