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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 state that the following indications for BRCA 1 and BRCA 2 testing are covered by Medicare: 
 
Personal history of breast, ovarian, pancreatic or prostate cancer with the following RISK 
Assessment (stratification) items (1-8 below) that are to be considered before testing in those patients with one 
of the four mentioned cancers that is suspected to be of hereditary origin. 
 
        Personal history of ovarian* carcinoma 
 
        Personal history of male breast cancer 
 
        Individual from a family with a known deleterious BRCA1/BRCA2 gene pathogenic mutation 
 
        Personal history of breast cancer and one or more of the following indications: 
            Diagnosed at 45 years of age or less; 
            Diagnosed at 50 years of age or less with: 
                An additional breast cancer primary at any age; 
                at least 1 close blood relative** with breast cancer at any age; 
                An unknown or limited family history; 
            Diagnosed at 60 years of age or less 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 with: 
                at least 1 close blood relative** with breast cancer diagnosed at 50 years of age or less; or 
                at least 1 close blood relative** with ovarian* cancer; or 
                at least 1 close blood relative** with pancreatic cancer; or 
                at least 1 close blood relative** with prostate cancer (Gleason score greater than or equal to 7 or 
metastatic); or 
                at least 1 close male blood relative** with breast cancer; or 
                at least 2 additional diagnoses of breast cancer in patient and/or in close blood relative(s) at any age; 
            Individual of ethnicity associated with higher pathogenic mutation frequency (e.g. Ashkenazi Jewish) 
 
        Personal history of pancreatic cancer 
         Personal history of prostate cancer (Gleason score greater than or equal to 7) at any age with 
            at least 1 close blood relative** with ovarian* cancer, pancreatic cancer, or metastatic*** prostate 
cancer at any age or breast cancer (at 50 years of age or less); or 
            at least 2 close blood relatives with breast cancer, or prostate cancer (any grade) at any age; or 
            Ashkenazi Jewish ancestry 
 
        Personal history of metastatic*** prostate cancer 
 
        BRCA1/2 pathogenic mutation detected by tumor profiling on any tumor type in the absence of germline 
pathogenic mutation analysis 
 
        Personal history of cancer types listed above with a family history only (significant limitations of 
interpreting test results for an unaffected individual exists and therefore are not a covered benefit): 
            First- or second-degree blood relative** meeting any of the above criteria 
            Third-degree blood relative* who has breast cancer or ovarian* carcinoma and who has at least 2 close 
blood relatives** with breast cancer (at least one with breast cancer at 50 years of age or less) or ovarian* 
carcinoma 
 
The following indications for BRCA 1 and BRCA 2 testing are covered by Medicare: 
 
Personal history of breast, ovarian, pancreatic or prostate cancer with the following RISK 
Assessment (stratification) items (1-8 below) that are to be considered before testing in those patients with one 
of the four mentioned cancers that is suspected to be of hereditary origin. 
 
        Personal history of ovarian* carcinoma 
 
        Personal history of male breast cancer 
 
        Individual from a family with a known deleterious BRCA1/BRCA2 gene pathogenic mutation 
 
        Personal history of breast cancer and one or more of the following indications: 
            Diagnosed at 45 years of age or less; 
            Diagnosed at 50 years of age or less with: 
                An additional breast cancer primary at any age; 
                at least 1 close blood relative** with breast cancer at any age; 
                An unknown or limited family history; 
            Diagnosed at 60 years of age or less 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 with: 
                at least 1 close blood relative** with breast cancer diagnosed at 50 years of age or less; or 
                at least 1 close blood relative** with ovarian* cancer; or 
                at least 1 close blood relative** with pancreatic cancer; or 
                at least 1 close blood relative** with prostate cancer (Gleason score greater than or equal to 7 or 
metastatic); or 
                at least 1 close male blood relative** with breast cancer; or 
                at least 2 additional diagnoses of breast cancer in patient and/or in close blood relative(s) at any age; 
            Individual of ethnicity associated with higher pathogenic mutation frequency (e.g. Ashkenazi Jewish) 
 
        Personal history of pancreatic cancer 
 
        Personal history of prostate cancer (Gleason score greater than or equal to 7) at any age with             at least 1 close blood relative** with ovarian* cancer, pancreatic cancer, or metastatic*** prostate 
cancer at any age or breast cancer (at 50 years of age or less); or 
            at least 2 close blood relatives with breast cancer, or prostate cancer (any grade) at any age; or 
            Ashkenazi Jewish ancestry 
 
        Personal history of metastatic*** prostate cancer 
 
        BRCA1/2 pathogenic mutation detected by tumor profiling on any tumor type in the absence of germline 
pathogenic mutation analysis 
 
        Personal history of cancer types listed above with a family history only (significant limitations of 
interpreting test results for an unaffected individual exists and therefore are not a covered benefit): 
            First- or second-degree blood relative** meeting any of the above criteria 
            Third-degree blood relative* who has breast cancer or ovarian* carcinoma and who has at least 2 close 
blood relatives** with breast cancer (at least one with breast cancer at 50 years of age or less) or ovarian* 
carcinoma 
 
You can find this information in the Local Coverage Determination (LCD) BRCA1 and BRCA2 Genetic 
Testing L36715. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.