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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 BRCA1 and BRCA2 testing consists of full sequence and duplication/deletion analysis. 
Genetic testing for a known mutation in a family may be limited to the known familial variant. 
 
The following indications for BRCA1 and BRCA2 testing are covered by Medicare: 
 
Criteria for Testing 
 
    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: 
        Diagnosed =45 y 
        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 
        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 
        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. 
        Male breast cancer     Personal history of prostate cancer (Gleason score=7) at any age with: 
        =1 first, second, or third degree relative5 with ovarian cancer at any age, or 
        =1 first, second, or third degree relative5 with breast cancer =50 y, or 
        =1 first, second, or third degree relative5  pancreatic cancer at any age, or 
        =1 first, second, or third degree relative5 with metastatic prostate cancer at any age, or 
        =2 first, second, or third degree relatives5 with breast cancer and/or pancreatic cancer and/or prostate 
cancer (any grad) at any age, or 
        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 
 
1. Includes fallopian tube and primary peritoneal cancers. BRCA  related ovarian cancers are associated with 
epithelial, non-mucinous histology. 
 
2. Two breast cancer primaries include bilateral (contralateral) disease or 2 or more clearly separate ipsilateral 
primary tumors either synchronously or asynchronously. 
 
3. Medicare 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. 
 
4. Testing 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. 
 
5. National Comprehensive Cancer Network (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. 
 
Multigene Panels*** 
 
The indications and limitations of coverage listed in National Coverage Determination (NCD) 90.2 Next-
Generation Sequencing (NGS) apply to genetic testing for susceptibility to breast or ovarian cancer. While the 
NGS NCD 90.2 B describes specific coverage criteria for nationally covered tests, 90.2 D permits coverage 
of other NGS as a diagnostic laboratory test for patients with cancer when performed and ordered according to 
the requirements described by the NCD. According to 90.2 D of the NGS NCD, AB Medicare Administrative 
Contractors (AB MACs) may cover next generation sequencing tests in patients with cancer. As such, genetic 
testing for susceptibility to breast or ovarian cancer with multi-gene NGS panels (not otherwise covered under 
NCD 90.2 B) 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 individuals 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. 
 
BRCA testing is limited to once-in-a-lifetime. If a patient has been previously tested for BRCA1 and BRCA2, 
repeat testing prior to Lynparza therapy is not reasonable and necessary and will not be covered by Medicare. 
 
Nationally Non-Covered Indications 
 
BRCA1/BRCA2 genetic testing is not reasonable and necessary, thus it is non-covered, for the following 
indications: 
 
    Genetic screening in the general population. Such testing is considered screening and is excluded by 
Medicare statute. An Advance Beneficiary Notice of Non-coverage (ABN) must be obtained for BRCA1 and 
BRCA2 testing for individuals without signs and symptoms of breast, ovarian or other hereditary cancer 
syndromes as indicated in this policy. 
 
    Testing of individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, 
pancreatic, or prostate cancer. Such testing is considered screening and is excluded by Medicare statute. An 
ABN must be obtained for BRCA1 and BRCA2 testing for individuals without signs and symptoms of breast, 
ovarian or other hereditary cancer syndromes as indicated in this policy. 
 
    Testing of individuals under 18 years of age. 
 
You can find these rules in the Local Coverage Determination (LCD) MolDX: 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.