Medicare Coverage Explanation for Genetic Testing

If you have Medicare, you may be wondering about coverage for genetic testing. Medicare does cover some types of genetic cancer diagnostic tests and a few other types of genetic testing. For your genetic testing to be covered by insurance, you must meet certain eligibility criteria.

In this article, we’ll take a closer look at what types of genetic tests are covered by Medicare.

Yes, Medicare covers just a few types of genetic testing if you meet Medicare-established requirements.

Genetic testing is typically used to screen, diagnose, or guide specific treatment. Medicare does not cover genetic tests to predict your risk for a condition or to detect an undiagnosed health condition.

Your doctor may recommend genetic testing in certain situations. For example, your inherited risks for certain conditions, and drug effectiveness can guide treatment for better outcomes.

Medicare covers certain types of genetic testing to help with diagnosis or with the treatment of particular conditions.

Examples include:

• molecular diagnostic genetic tests (MDT)
• Next Generation Sequencing (NGS) genetic testing, also called multigene panel testing
• PGx genetic testing for certain medications

MDT involves analyzing gene sequences for mutations for specific diseases.

NGS is a form of genetic testing that examines multiple human DNA sequences at one time. It helps doctors understand how changes (mutations) in your DNA may predict risk factors and help diagnose conditions.

Medicare also covers pharmacogenomics (PGx). This is a type of genetic testing to learn how your body responds to certain types of medications. PGx helps improve drug therapy with targeted, effective treatment.

Medicare does not cover home genetic testing except one test. The Cologuard™ stool DNA test for colorectal cancer screening. This test is covered by Medicare Part B once every three years if you meet Medicare eligibility requirements.

Medicare does cover other forms of screening and diagnostic tests for health conditions like cancer, diabetes, depression and more. Your Medicare provider can give you more information on all the screening and preventive services covered by your Medicare plan.

Medicare covers a few different types of genetic testing for specific conditions typically under Original Medicare Part B diagnostic benefits. Your genetic testing may also be covered under Medicare Advantage (Part C) if you have that plan. In addition, Medicare Advantage plans offer some additional benefits over Original Medicare (dental, hearing, vision, wellness).

But beware, there are a lot of scams when it comes to genetic testing. Always check with your doctor and Medicare Plan before taking a genetic test. Medicare does not cover genetic tests for disease prevention.

Does Medicare cover genetic testing for cancer?

Medicare will cover some specific types of diagnostic genetic testing for cancer. These tests help identify abnormal cell activities in your body (biomarkers). For example, Medicare covers diagnostic testing for breast cancer, prostate cancer, ovarian cancer, and pancreatic cancer for people who have not been tested before for specific mutations (BRCA).

Medicare also covers NGS genetic testing for both acquired (cancer from gene mutations) and germline (inherited) cancer.

Medicare covers NGS if you:

• 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.

Coverage can vary depending on where you live. Medicare Administrative Contractors (MACs) decide coverage in your area. Mac’s are Medicare-approved private insurance providers. It’s important to check with your Medicare provider about specific genetic testing coverage.

Your cost for a genetic test depends on the specific test being done, how it’s done (saliva, blood sample) and if you meet Medicare coverage criteria.

If your test is covered, you’ll pay nothing as long as your provider accepts assignment. This means they agree to Medicare set payment terms.

Genetic testing costs can run anywhere from several hundred to several thousand dollars. So, it’s worthwhile to make sure Medicare covers the test.

You must meet certain eligibility rules set by Medicare, and it must be ordered by your physician. MAC’s may also have local eligibility requirements.

It’s always a good idea to check with your doctor before genetic testing.

Questions to consider asking:

• how will genetic testing benefit me?
• should I worry about confidentiality?
• will Medicare cover my test?
• what costs do I need to pay?
• does the lab accept assignment?

You can also contact your Medicare provider to ask about specific genetic testing coverage and costs.

Medicare covers genetic testing for some specific conditions and PGx for medications if it is ordered by your physician and done in a Clinical Laboratory Improvement Amendments (CLIA) certified lab.

Medicare covers genetic diagnostic testing for specific gene mutations, and NGS multi-gene panel testing if you have a cancer diagnosis. NGS testing is also covered for other inherited conditions like heart problems (cardiomyopathy – heart muscle problem, arrhythmia) if you meet Medicare requirements. Individual Plan coverage may vary depending on where you live.

PGx testing is also covered for specific medications. Certain enzymes like CYP2C19, CYP2D6, and CYP2C9 found in the liver help break down many medications. Genetic testing for these enzymes helps doctors and pharmacists better target your medication therapy.

Medicare covers PGx testing for some specific medications (warfarin, clopidogrel, amitriptyline, others) if criteria for testing are met. Your doctor can provide more information about PGx testing benefits for you. Your Medicare plan provider can tell you what PGx tests are covered by your plan.

In addition, Medicare allows MACs to decide if they will cover non-FDA approved NGS and other types of NGS genetic testing. For example, for other cancers and other health conditions.

Yes. Medicare covers genetic testing for BRCA 1 and BRCA 2 gene mutations. There are several types of diagnostic genetic tests for BRCA covered by Medicare.

Medicare also covers NGS testing for breast cancer and ovarian cancer. Research shows people with the BRCA 1 or BRCA 2 gene mutations (male and female) are at much higher risk for breast and ovarian cancer compared to people who do not have these gene mutations.

A multigene panel test like NGS can help identify BRCA 1, BRCA 2 and other gene mutations in one test to help with a cancer diagnosis.

Some criteria for BRCA 1 and BRCA 2 testing:

• you have a history of ovarian, breast, fallopian tube, primary peritoneal, pancreatic, or prostate cancer
• breast cancer diagnosis with other age and hereditary risk-specific criteria
• close relation with BRCA1 or BRCA2 gene mutation
• Ashkenazi Jewish heritage
• you have risk factors for hereditary breast or ovarian cancer
• you haven’t been tested with NGS previously for the same hereditary cancers

To qualify for NGS testing:

• you must receive pre testing genetic counseling
• multi-gene testing must be relevant based on your family history of cancer
• you must meet eligibility criteria testing for breast cancer or other cancer and one other type of hereditary cancer based on National Comprehensive Cancer Network guidelines (i.e., Lynch Syndrome, Cowden Syndrome)

Your doctor or Medicare provider can give you details on eligibility criteria for BRCA1 and BRCA 2 genetic testing and for NGS genetic testing.

It depends. According to Medicare guidelines, genetic counseling provided by a “cancer genetics professional” such as a physician is covered. However, you must be a patient of that physician.

Medicare does not currently recognize certified genetic counselors as healthcare providers. So, if you go to a certified genetic counselor, your visit may not be covered.

Certified genetic counselors have special training and experience with genetics and counseling to help you understand your hereditary risks for certain diseases such as cancer.

Medicare also does not cover genetic counseling for any screening or prevention testing based on current regulations.

Your Medicare plan provider can provide more information on genetic counseling coverage requirements.