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 the following indications for BRCA1 and BRCA2 testing are covered by Medicare: 
 
Individual with breast, ovarian
1
, pancreatic, or prostate cancer from a family with a known deleterious BRCA1 
or BRCA2 gene mutation 
 Individual with a personal history of ovarian
1*
 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 relative
5
 with breast cancer at any age, or 
 1 first, second, or third degree relative
5
 with prostate cancer (Gleason score 7), or 
 An unknown or limited family history
3
 
o Breast cancer diagnosed at any age, and  
 1 first, second, or third degree relative
5
 with breast cancer 50 y, or 
 1 first, second, or third degree relative
5
 with ovarian cancer at any age, or 
 1 first, second, or third degree relative
5
 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 
relative
5
, 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 
Jewish
4
) 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 relative
5
 with ovarian cancer at any age, or 
o 1 first, second, or third degree relative
5
 with breast cancer 50 y, or 
o 1 first, second, or third degree relative
5
 with pancreatic cancer at any age, or 
o 1 first, second, or third degree relative
5
 with metastatic prostate cancer at any age, or 
o 2 first, second, or third degree relatives
5
 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 
Multigene panels for HBOC syndromes are available. In general, these panels test simultaneously for several 
genes associated with inherited breast and/or ovarian cancer, including but not limited to the BRCA1 and 
BRCA2 genes. The genes included and the methods used in multigene panels vary by laboratory. Some cancer 
susceptibility testing panels include genes that have not been associated with hereditary breast or ovarian 
cancer and, in some cases, are not clinically actionable. Testing with a targeted panel may be indicated as a cost 
effective strategy when the individuals symptoms or family history meet testing criteria for more than 1 
hereditary cancer syndrome. All genes included in the test should be relevant to the personal and family history 
for the individual being tested. 
 
You can find these rules 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.