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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 Germline genetic testing of BRCA1 and BRCA2 is available to identify individuals at 
increased risk for breast and ovarian cancers, as individuals with an inherited cancer syndrome may benefit 
from screening and prevention strategies to reduce their risk. 
 
BRCA1 and BRCA2 genetic testing has been found to be reasonable and necessary in the following instances. 
 
1. Personal History of Female Breast Cancer 
 
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: 
 
    a. Diagnosed at age 45 or younger; 
    b. Diagnosed at age 50 or younger with at least one close blood relative* with breast cancer at any age; 
    c. 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; 
    d. 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); 
    e. 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; 
    f. 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); 
    g. Diagnosed at any age and there are at least two close blood relatives* with breast cancer at any age; 
    h. Diagnosed at any age with at least one close blood relative* with breast cancer at age 50 or younger; 
    i. Diagnosed at any age with at least one close blood relative* with epithelial ovarian cancer, fallopian tube, 
or primary peritoneal cancer; 
    j. Close male blood relative* with breast cancer; 
    k. 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. 
 
 
 *NCCN defines blood relative as first- (parents, siblings and children), second- (grandparents, aunts, uncles, 
nieces and nephews, grandchildren and half-siblings), and third degree-relatives (great-grandparents, great-
aunts, great uncles, great grandchildren and first cousins) on same side of family. 
 
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 this rule in the 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.