Appeal type: unknown
Decision: unknown

 
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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
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 >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. 
Genetic testing for a known mutation in a family is a covered service for individuals with signs and/or 
symptoms of breast cancer. Testing of an unaffected Medicare eligible individual or family member is not a 
covered Medicare service. You can find the rules in Local Coverage Determination (LCD) BRCA1 and 
BRCA2 Genetic Testing L36499. 

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.