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FORCE Publications

Stricter Medicare Guidelines for Coverage of BRCA Testing

by Sue Friedman

In June of 2006 Medicare revised its guidelines for coverage of BRCA genetic testing. The more stringent new rules provide coverage for fewer high-risk people. Prior guidelines approved genetic testing for any woman diagnosed with ovarian cancer and any man diagnosed with breast cancer. Under the new rules, these same individuals must meet additional criteria, such as having another breast or ovarian cancer survivor in the family, or be of Ashkenazi Jewish descent.

Earlier guidelines approved genetic testing for family members of individuals with a known BRCA mutation. Now only people diagnosed with cancer are covered. Those who have not been diagnosed with cancer are not covered under any circumstance. Further, the law requires physicians to demonstrate a medical benefit to the person being tested. For example, a woman with stage 4 ovarian cancer who is undergoing testing to inform her family about their risk may not be covered under the new guidelines, unless the results would change her own treatment or followup.

The Social Security Act of 1935, the law that created Medicare, states that benefits do not include testing in the absence of signs or symptoms of illness or injury. By this definition, testing for a BRCA mutation in someone without cancer is interpreted as “screening.” Medicare does provide coverage for some screening tests, including mammography, colonoscopy and PSA tests—congressional statues were required to add these to the list of approved services. Similar legislation would be needed before Medicare provides coverage of BRCA testing for high-risk individuals who have never had cancer.

Coverage for Genetic Testing

For more information on Medicare and other programs’ coverage for genetics testing, see our “Financial Help” section.

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