Medicare coverage of genetic services
Under Medicare’s guidelines, BRCA1 and BRCA2 genetic testing is covered for people with:
- A personal history of breast cancer, with one or more of the following:
- diagnosed at or before age 45, with or without family history
- diagnosed at or before age 50 or two breast primaries, with 1 or more close blood relative(s) with breast cancer diagnosed at or before age 50 or 1 or more close blood relative(s) with ovarian cancer/fallopian tube/primary peritoneal cancer
- two breast primaries when first breast cancer diagnosis occurred prior to age 50
- diagnosed at any age, with 2 or more close blood relatives with breast and/or epithelial ovarian/fallopian tube/primary peritoneal cancer, at any age
- close male blood relative with breast cancer
- personal history of epithelial ovarian/fallopian tube/primary peritoneal cancer
- of a certain ethnicity associated with higher mutation frequency, (eg, founder populations of Ashkenazi Jewish, Icelandic, Swedish, Hungarian or other) no additional family history required
- a close relative with a known BRCA1 or BRCA2 gene mutation
- Personal history of epithelial ovarian/fallopian tube/primary peritoneal cancer.
- Personal history of male breast cancer.
Medicare operates on a regional system in which Medicare Area Contractors (MACs) manage the provision of health services for a specific jurisdiction. In the spring of 2015, four MACs expanded their coverage to better align their services with National Comprehensive Cancer Network (NCCN) guidelines in a number of important areas, including:
- Expanding coverage of genetic testing for individuals who have or had cancer consistent with hereditary cancer syndromes, including men diagnosed with prostate cancer and men and women diagnosed with pancreatic cancer,
- Coverage of multigene testing panels if more than one mutation may be indicated, and
- Clarification of the BRCA testing policy for use of the targeted therapy, Lynparza (olaparib).
It is important to note that these policy changes apply only to states covered by the four MACs:
Arkansas, Arizona, California, Hawaii, Idaho, Kentucky, Montana, Nevada, North Carolina, North Dakota, Ohio, Oregon, South Carolina, South Dakota, Utah, Virginia, Washington, West Virginia and Wyoming
Medicare does not currently cover the cost of genetic testing in individuals who do not have a personal history of cancer.