Medicare coverage of genetic services
Hereditary cancer genetic counseling and testing is covered by Medicare under certain conditions for people already diagnosed with cancer.* In 2019, Medicare implemented a new national policy indicating that the following criteria must be met to qualify for coverage of genetic testing.
The patient has:
- recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and,
- not previously tested using the same genetic test for the same cancer diagnosis (repeat testing using the same genetic test is covered only when a new primary cancer diagnosis is made); and,
- decided to seek further cancer treatment (e.g., chemotherapy).
The laboratory/genetic test must have:
- Food & Drug Administration (FDA) approval or clearance as a companion diagnostic; and,
- an FDA-approved or -cleared drug/treatment for use in the patient’s cancer; and,
- results provided to the physician for management of the patient’s cancer using a report that specifies treatment options
There may be some exceptions to the above policy to allow for genetic testing of people with earlier stage cancers. Your health care provider or genetic counselor should be able to guide you regarding the appropriate genetic test and insurance coverage. If you have trouble accessing or obtaining coverage of needed genetic testing, visit this page to learn about financial assistance or reduced-cost testing options.
*NOTE: Medicare does not cover genetic testing for individuals who do not have not been diagnosed with cancer.
Updated 05/29/2019
