Does Medicare Cover Genetic Testing for Breast Cancer?

Genetic testing for breast cancer helps assess risk and guide treatment decisions. This article outlines Medicare’s coverage for these tests, detailing the conditions for coverage, steps to navigate the process, and potential financial responsibilities.

Understanding Medicare Coverage for Breast Cancer Genetic Testing

Medicare coverage for breast cancer genetic testing primarily falls under Medicare Part B, which covers medically necessary outpatient services. For a genetic test to be considered medically necessary, specific criteria must be met. These criteria often relate to an individual’s personal or family medical history, indicating an elevated risk for hereditary breast and ovarian cancer syndromes.

One common criterion for coverage involves a personal history of certain cancers, such as breast cancer diagnosed at a younger age, ovarian cancer, pancreatic cancer, or metastatic prostate cancer. Coverage may also extend to individuals with a personal history of triple-negative breast cancer. Additionally, a strong family history of these cancers, particularly among close relatives, can establish medical necessity for genetic testing.

The genetic tests covered by Medicare often include analysis for specific genes, most notably BRCA1 and BRCA2. These genes are associated with an increased risk of hereditary breast and ovarian cancers. While BRCA1 and BRCA2 are the most common, Medicare may also cover testing for other genes if deemed medically necessary based on clinical guidelines and the beneficiary’s specific risk factors.

Navigating the Process for Coverage

Medicare coverage for breast cancer genetic testing begins with a physician’s order. A healthcare provider, such as an oncologist or genetic counselor, must determine that the testing is medically appropriate based on the established criteria. This order serves as the foundational document for initiating the testing process and submitting claims to Medicare.

Once medical necessity is established, ensure the genetic testing is performed by a laboratory that is approved by Medicare. Medicare-approved laboratories meet specific federal quality standards and are authorized to bill Medicare for their services. Beneficiaries or their providers should confirm the laboratory’s Medicare approval status before samples are submitted.

Prior authorization may be required by Medicare for certain genetic tests. If prior authorization is needed, the healthcare provider’s office or the testing laboratory typically handles this process, submitting the necessary documentation to Medicare for approval before the test is performed. The provider or the laboratory generally submits the claim directly to Medicare after the test is completed.

Financial Aspects and What Happens Next

Even when Medicare covers breast cancer genetic testing, beneficiaries may still have out-of-pocket costs. For services covered under Medicare Part B, an annual deductible applies. After the deductible is met, Medicare typically pays 80% of the Medicare-approved amount for the service, leaving the beneficiary responsible for the remaining 20% coinsurance.

Medicare Advantage Plans, also known as Medicare Part C, are offered by private companies approved by Medicare. These plans are required to cover at least the same services as Original Medicare, including medically necessary genetic testing for breast cancer. However, Medicare Advantage Plans may have different cost-sharing structures, such as varying deductibles, copayments, or coinsurance amounts, and may require beneficiaries to use in-network providers or laboratories.

Medicare Supplement Insurance Plans, or Medigap policies, can help cover some of the out-of-pocket costs associated with Original Medicare. These plans can assist with paying the Part B coinsurance and deductible. If a claim for genetic testing is initially denied by Medicare, beneficiaries have the right to appeal the decision. The appeal process typically involves several levels, beginning with a redetermination by Medicare, and requires submitting additional documentation to support the medical necessity of the test.

Citations

Medicare.gov.