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 Covered Indications: 
 
This is a limited coverage LCD for BRCA1 and BRCA2 genetic testing. 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: 
 
    Diagnosed at age 45 or younger; 
    Diagnosed at age 50 or younger with at least one close blood relative* with breast cancer at any age; 
    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; 
    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); 
    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; 
    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); 
    Diagnosed at any age and there are at least two close blood relatives* with breast cancer at any age; 
    Diagnosed at any age with at least one close blood relative* with breast cancer at age 50 or younger; 
    Diagnosed at any age with at least one close blood relative* with epithelial ovarian cancer, fallopian tube, or 
primary peritoneal cancer; 
    Close male blood relative* with breast cancer; 
    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. 
 
2. Personal History of Other Cancer 
 
BRCA1 and BRCA2 genetic testing for susceptibility to breast or ovarian cancer is covered in adults as 
medically necessary when there is a personal history of ANY of the following indications: 
 
    Personal history of epithelial ovarian, fallopian tube, or primary peritoneal cancer; 
    Personal history of male breast cancer; 
    Personal history of pancreatic cancer or prostate cancer with Gleason score =7 at any age, =1 close blood 
relatives* with breast (=50 y), invasive ovarian, pancreatic cancer, or prostate cancer with Gleason score =7 at 
any age; 
    Personal history of pancreatic cancer at any age with Ashkenazi Jewish ancestry (Begin testing with 
Ashkenazi Jewish founder specific mutations). If negative, complete analysis should be performed. Complete 
analysis may be considered if ancestry also includes non-Ashkenazi Jewish relatives and 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 another inheritable cancer. Testing of an unaffected Medicare eligible individual or family 
member is not a covered Medicare service. 
 
Medicare will cover BRCA-testing for an adopted individual with breast or ovarian cancer diagnosed = 45 y or 
= 60 y with triple negative breast cancer, or has a personal history of an "other" cancer (see above) that is 
suspicious of being a BRCA-related cancer. Individuals with little known family health history, come from 
small families, and in the case of sex-specific conditions, have few female/male relatives at risk of developing a 
particular condition, 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. 
 
You can find this information in Medicare's 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.