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Does Medicare Cover Genetic Testing?

Medicare provides coverage for specific types of genetic testing, which can be crucial for identifying genetic risks and guiding treatment decisions. This article will explore the genetic testing options covered by Medicare and the eligibility criteria for receiving coverage. We'll also discuss the various genetic tests covered under Medicare, including Next Generation Sequencing (NGS) and molecular diagnostic genetic tests.

Key takeaways:

Understanding Medicare's coverage for genetic testing can help beneficiaries make informed decisions about their healthcare options.

Types of genetic testing covered by Medicare

Under Medicare, certain genetic tests are eligible for coverage, offering beneficiaries access to cutting-edge medical advancements.

These tests include:

  • Next Generation Sequencing (NGS). A powerful genetic testing method that simultaneously examines multiple human DNA sequences. NGS enables healthcare providers to predict risk factors and diagnose conditions with increased accuracy.
  • Molecular Diagnostic Genetic Tests (MDT). Another covered option that involves analyzing gene sequences to identify specific diseases.
  • Pharmacogenomic testing (PGx). A revolutionary genetic testing approach that delves into how an individual's body responds to specific medications. PGx testing facilitates personalized drug therapy, tailoring treatments to each patient's genetic makeup and potentially enhancing treatment outcomes.
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Medicare coverage for cancer genetic testing

Medicare covers specific types of diagnostic genetic testing for cancer, including breast, prostate, ovarian, and pancreatic cancer. This coverage extends to both acquired (cancer from gene mutations) and germline (inherited) cancer. To be eligible for coverage, individuals must have advanced stage III or IV cancer, recurrent, relapsed, metastatic, or refractory cancer, and have not undergone NGS testing for the same inherited cancer type.

Medicare also expanded NGS coverage to include breast and ovarian cancer in all stages in 2020. However, coverage may vary depending on the location, as Medicare Administrative Contractors (MACs) decide coverage in specific areas.

Medicare coverage for BRCA genetic testing

Medicare covers genetic testing for BRCA 1 and BRCA 2 gene mutations, which significantly increase the risk of breast and ovarian cancer. Multigene panel tests, like NGS, can identify these gene mutations and aid in cancer diagnosis.

Eligibility criteria for BRCA 1 and BRCA 2 testing include a history of relevant cancers, close relations with the gene mutations, Ashkenazi Jewish heritage, and specific risk factors for hereditary breast or ovarian cancer. NGS testing for breast cancer or other hereditary cancers also requires pre-testing genetic counseling and meeting eligibility criteria based on National Comprehensive Cancer Network guidelines.

Genetic testing eligibility and costs under Medicare

To be eligible for genetic testing coverage under Medicare, the test must be ordered and received by a physician, FDA-approved, and deemed medically necessary. Medicare does not cover genetic tests for disease prediction or undiagnosed health conditions.

Beneficiaries need to check with their coverage provider to determine if their specific genetic test is covered and understand any potential costs. The cost of a genetic test can vary depending on the particular test and how it's conducted, ranging from several hundred to several thousand dollars if not covered by Medicare.

Beneficiaries pay nothing if the test is covered and their provider accepts Medicare's payment terms. However, verifying local eligibility requirements is essential, as Medicare Administrative Contractors (MACs) may have specific coverage guidelines.

Genetic counseling coverage under Medicare

Medicare covers genetic counseling provided by a "cancer genetics professional," such as a physician, but only if the patient is under the care of that physician. Unfortunately, Medicare does not recognize certified genetic counselors as healthcare providers, so their services may not be covered.

Genetic counseling is crucial for understanding hereditary risks for certain diseases. Still, Medicare does not cover counseling for screening or prevention testing based on current regulations.

What is genetic counseling?

Genetic counseling is a specialized healthcare service that helps individuals and families understand genetic conditions' potential risks and implications. It involves a collaborative process between a certified genetic counselor and the patient. It aims to provide comprehensive information and support to make informed decisions about genetic testing, treatment options, and family planning.

What does a genetic counselor do?

Genetic counseling sessions can help individuals assess their risk of developing specific conditions, better understand family health history, and receive personalized recommendations for preventive measures or treatment plans. It can also address concerns related to hereditary conditions and assist individuals in making informed choices about genetic testing.

Genetic counseling is vital in supporting patients throughout their genetic testing journey. It provides them with the knowledge and support they need to make informed decisions about their health and well-being.

How to check Medicare coverage for genetic testing

For Medicare beneficiaries, genetic counseling is often a necessary step before undergoing certain genetic tests, especially for hereditary cancer-related testing, like BRCA 1 and BRCA 2 gene mutations. While Medicare does cover genetic counseling provided by a "cancer genetics professional," it's important to note that certified genetic counselors are not currently recognized as healthcare providers by Medicare, potentially limiting coverage options.

You must check with your Medicare provider to determine if Medicare covers your genetic test. Each type of genetic testing covered by Medicare has specific eligibility criteria, and coverage can vary depending on the location and Medicare Administrative Contractors (MACs). Consulting your physician and Medicare plan provider will ensure you have the most accurate and up-to-date information regarding coverage and any potential costs.

Overall, Medicare does offer coverage for certain types of genetic testing, such as Next Generation Sequencing, molecular diagnostic genetic tests, and PGx genetic testing for specific medications. The coverage is primarily focused on diagnostic testing for cancer and inherited conditions.

However, beneficiaries need to verify eligibility and coverage with their Medicare provider and understand any potential costs associated with the testing. Genetic testing can be crucial in guiding treatment decisions and managing health conditions, making it essential for Medicare beneficiaries to stay informed about their coverage options.


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