Does Medicare Cover DNA Testing?
Key Takeaways
- Medicare may pay for genetic testing if you have cancer or a high risk of developing cancer.
- The types of genetic testing Medicare commonly covers include molecular genetic tests, next-generation sequencing, pharmacogenetics, Cologuard, and blood-based biomarker tests.
- To be covered, all tests must be ordered and received by a physician, approved by the Food and Drug Administration (FDA), and medically necessary.
- It’s important to check whether your genetic test is covered by your insurance and what costs you’ll pay out of pocket.
Does Medicare cover genetic testing? Yes, but only under specific circumstances. Genetic testing can identify inherited traits or mutations that lead to cancer or other serious health conditions. For example, if you have the BRCA genes, you have a higher risk of developing breast, ovarian, and other cancers. A genetic test may help you learn more about your health risks and take preventive measures.
Keep reading to learn more about the types of genetic testing Medicare may cover and the eligibility criteria.
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What Types of Genetic Testing May Be Covered?
Medicare is selective about the types of genetic tests it covers. Here are the tests it may cover in specific scenarios:
- Molecular genetic tests (MDT)
- Next-generation sequencing (NGS)
- Pharmacogenomics (PGx)
- Cologuard™ multi-target stool DNA (sDNA) test
- Blood-based biomarker screening tests for colorectal cancer
Molecular Genetic Tests (MDT)
Molecular diagnostic genetic tests analyze gene sequences for mutations that result in specific diseases. For example, this is the type of test doctors use to find mutations in the BRCA1 and BRCA2 genes. They can also use MDT to look for mutations in other disease-causing genes, including:
- ATM gene, which can cause breast and bladder cancers
- PALB2 gene, which can cause breast, pancreatic, and ovarian cancers
- CHEK2 gene, which can cause breast and colorectal cancers
Next-generation Sequencing (NGS)
Next-generation sequencing (NGS) genetic testing, also known as multigene panel testing, examines multiple human DNA sequences simultaneously. Rather than isolate your DNA for one specific gene, doctors will look for every possible mutation that could affect your health.
NGS helps doctors understand how mutations in your DNA may predict risk factors and aid in diagnosing conditions.
Pharmacogenomics (PGx)
Pharmacogenomics (PGx) testing shows how your body responds to certain types of medications. PGx helps improve drug therapy with targeted, effective treatment. Currently, doctors are using it to create tailored drugs for patients with:
- Cardiovascular disease
- Cancer
- Diabetes
- Autoimmune disorders
- Mental health disorders
Cologuard™ Multi-target Stool DNA (sDNA) Test
The Cologuard stool test is an at-home test that analyzes your stool for signs of cancer. It looks for 10 different DNA markers in your sample that can be early warning signs of colon cancer.
Blood-based Biomarker Screening Tests for Colorectal Cancer
Like the stool DNA test, a blood-based biomarker screening test looks for biomarkers in your DNA. While this test is non-invasive, it can miss certain polyps and cancers. There are two FDA-approved tests available: Shield and ColoHealth.
When Does Medicare Pay for Genetic Testing?
Medicare Part B covers genetic testing to determine treatment for a health condition. Your doctor must prescribe the test and declare it medically necessary. Medicare usually covers the full cost of diagnostic laboratory tests.
Medicare might also cover a genetic test if you’re having symptoms or are at a high risk for a certain condition.
PGx testing is covered for specific medications you might need. For example, certain enzymes found in the liver, such as CYP2C19, CYP2D6, and CYP2C9, help break down many medications. Genetic testing for these enzymes allows doctors and pharmacists to target your medication therapy.
Does Medicare Advantage Pay For Genetic Testing?
If you have Medicare Advantage instead of Original Medicare, your plan must at least match the coverage for testing that you would get through Original Medicare. However, your plan may require you to see a doctor in your provider network to get the most from your benefits.
Does Medicare Cover Genetic Testing for Cancer?
Medicare covers genetic diagnostic testing for specific gene mutations and NGS multi-gene panel testing if you have a cancer diagnosis. For example, Medicare covers the breast cancer gene (BRCA) test, looking for gene changes that heighten risks for not only breast cancer, but also prostate cancer, ovarian cancer, and pancreatic cancer.
Knowing whether a genetic mutation has caused your cancer can affect your treatment. For example, cancers caused by BRCA can be treated with a type of drug called PARP inhibitors that block cancerous cells from repairing themselves and reproducing.
In addition, Medicare covers NGS genetic testing for both acquired (cancer from gene mutations) and germline (inherited) cancer if you meet the following criteria:
- Have advanced stage III or IV cancer, cancer that is recurrent, relapsed, metastatic, or refractory (treatment resistant).
- Haven’t had an NGS test already for the same germline (inherited) type cancer.
- Want to receive further cancer treatment.
In 2020, CMS also expanded NGS coverage to include testing for ovarian and breast cancer in all stages.
Does Medicare Cover BRCA Testing?
Medicare covers genetic testing for BRCA1 and BRCA2 gene mutations for some people. These genes are associated with a higher risk of breast and ovarian cancers.
A multigene panel test like NGS can help identify BRCA1, BRCA2, and other gene mutations in one test to help with a cancer diagnosis.
Some criteria that could qualify you for BRCA1 and BRCA2 testing are:
- A history of ovarian, breast, fallopian tube, primary peritoneal, pancreatic, or prostate cancer
- A breast cancer diagnosis with other age and hereditary risk-specific criteria
- A close relation with BRCA1 or BRCA2 gene mutation
- Ashkenazi Jewish heritage
- Risk factors for hereditary breast or ovarian cancer
- You haven’t been tested with NGS previously for the same hereditary cancers.
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Does Medicare Cover Genetic Counseling?
Medicare covers genetic counseling provided by your doctor. However, it won’t cover counseling from a specialized genetic counselor. Even though certified genetic counselors have special training and experience to help you understand your hereditary risks for certain diseases, Medicare doesn’t currently recognize these counselors as healthcare providers.
Medicare also does not currently cover genetic counseling for screening or prevention testing. Overall, genetic counseling is a valuable tool for older adults who have symptoms or a family history of a condition like:
- Hereditary breast and ovarian cancer syndrome
- Lynch syndrome (hereditary colorectal and other cancers)
- Familial hypercholesterolemia
- Muscular dystrophy
- Movement disorders such as Huntington’s disease
Beware of Medicare Genetic Testing Scams
Watch out for scams when it comes to genetic testing, especially if you hear from a person or company offering “free” testing or an immunodeficiency genetic test under Medicare. This is often a trick that can leave you stuck with a big bill.
The goal of these scammers is to obtain your Medicare number to steal your medical identity. They may also want to bill Medicare for fraudulent charges to receive a payout.
To keep yourself safe, follow these tips:
- Be cautious about sharing your Medicare information with anyone you have not contacted first.
- Never accept genetic testing services offered at a large event.
- Don’t use a genetic testing kit sent by mail unless ordered by your doctor.
- Check your Medicare Summary Notice or Explanation of Benefits regularly for any suspicious charges.
- Always check with your doctor before taking a genetic test.
Does Medicaid Cover Genetic Testing?
Medicaid provides health insurance for U.S. adults with low incomes. Individual states administer this program, so coverage details for genetic testing differ based on where you live.
Most state Medicaid programs cover testing for the BRCA gene and a Lynch syndrome mutation — the most common cause of hereditary colorectal cancer — for people who have a known genetic mutation in their family or either a personal or family history of cancer.
However, the majority of Medicaid programs don’t cover testing for many other specific mutations or for multigene panel testing, which checks for inherited mutations in multiple genes at once. Check with your state’s Medicaid office to learn more about what genetic testing options may be available to you.
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Putting It All Together
Does Medicare cover genetic testing? Sometimes. Medicare typically only pays for genetic testing if you have a disease or are at risk of getting a disease that a faulty gene could cause. If you aren’t at high risk or don’t have symptoms of a particular condition, you will likely have to pay for genetic testing costs out of pocket.
Sources
- Medicare & Medicaid. Facing Our Risk of Cancer Empowered.
- ATM gene. MedlinePlus.gov.
- PALB2 Gene Mutations: Cancer Risk. Facing Our Risk of Cancer Empowered.
- CHEK2 Gene Mutations: Cancer Risk. Facing Our Risk of Cancer Empowered.
- Pharmacogenomic and pharmacogenetic-guided therapy as a tool in precision medicine: current state and factors impacting acceptance by stakeholders. National Library of Medicine.
- Cologuard. Exact Sciences.
- Colorectal Cancer Screening Tests. American Cancer Society.
- The Effect of Cytochrome P450 Metabolism on Drug Response, Interactions, and Adverse Effects. American Family Physician.
- BRCA Gene Changes: Cancer Risk and Genetic Testing. National Cancer Institute.
- CMS Expands Coverage of Next Generation Sequencing as a Diagnostic Tool for Patients with Breast and Ovarian Cancer. CMS.gov.
- BRCA1 and BRCA2 Genetic Testing. CMS.gov.
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