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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 the following indications for BRCA1 and BRCA2 testing are covered by Medicare: - 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 with 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 grade) 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 Genetic testing for susceptibility to breast or ovarian cancer with multi-gene NGS panels may be covered by this AB MAC as reasonable and necessary when ALL of the NCD criteria are met in addition to the following: - Pretest genetic counseling by a cancer genetics professional has been performed and posttest genetic counseling by a cancer genetics professional meeting NCCN accreditation criteria is planned; - All genes in the panel are relevant to the personal and family history for the individual being tested (panels with genes that are not relevant to the individual's personal and family history are not reasonable and necessary); - Criteria listed under "Personal History of Female Breast Cancer" and/or "Personal History of Other Cancer" are met; - Individual also meets criteria for at least 1 hereditary cancer syndrome for which NCCN guidelines provide clear testing criteria and management recommendations, including but not limited to Hereditary Breast and Ovarian Cancer Syndrome (HBOC), LiFraumeni Syndrome, Cowden Syndrome, or Lynch Syndrome. You can find this rule at Local Coverage Determination (LCD) L36161: MolDX: BRCA1 and BRCA2 Genetic Testing (eff. 4/29/21).  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.