Does Insurance Pay for BRCA Testing?

BRCA stands for the breast cancer gene. There are two types of BRCA genes that are seen to be influencing a person’s chances of getting breast cancer. These are brca1 and brca2 genes. Each one of us has both the genes. These genes themselves are not responsible for causing cancer. They are in fact our caretaker genes for cancer.

They are known as tumor suppressor genes. They help in repairing any broken DNA, thus keeping us safe from cancer. However, when these genes get broken or altered, it compromises their functioning capacity. This is known as gene mutation. Because of this, the people who have a BRCA gene mutation are prone to get affected by breast cancer. This risk can also be passed to the affected person’s children, with a chance of 50%.

Does Insurance Pay for BRCA Testing?

Does Insurance Pay for BRCA Testing?

Medicare is the federal health insurance program. the guidelines for BRCA testing have been revised by Medicare of late, making them more stringent for BRCA testing.

Previously, any woman, who was diagnosed with ovarian cancer was approved for taking up genetic testing for BRCA. Same was true for any man being diagnosed with breast cancer. However, these days many new additions have been done, thus making the guidelines more stringent. For example, a woman with ovarian cancer must also be able to meet additional criteria of having any breast or ovarian cancer survivor in the family.

Also, previously, the family members of the people with a known BRCA gene mutation, were given approval for the genetic testing. However, nowadays only the people who have been diagnosed with cancer are approved for the genetic testing. Those persons, who are not diagnosed with cancer are not provided with coverage for genetic testing, no matter what. Also, now the physicians are required to show what benefits the genetic testing is going to do to the patient, to get the approval.

The social security act says that if signs and symptoms of an illness are not present, the coverage benefits will not include testing. So for someone without cancer, such kind of testing is known as screening and Medicare does not approve some screening tests for coverage, and this includes mammography as well.

Medicare provides coverage for the BRCA testing if-

A person is diagnosed with BRCA at an age of 45 or before that. The family history may or may not be present

A person is diagnosed at an age of 50 or before that and one or more immediate relations are diagnosed with breast cancer before or at the age of 50 or one or more immediate relations are diagnosed with ovarian or fallopian tube cancer.

  • Two close relations with breast cancer diagnosed before the age of 50.
  • A person is diagnosed at any age and with two or more immediate relations with breast cancer.
  • Person is suffering from other cancer like fallopian tube cancer, ovarian cancer etc.
  • In persons belonging to a certain population like Swedish, Icelandic, Hungarian etc.

As Medicare functions on a regional system, the coverage has been expanded in alignment with national comprehensive cancer network (NCCN). This includes-

  • Coverage for persons who are affected by hereditary cancer syndromes
  • Multigene testing panel is covered if more than one gene mutation is indicated.
  • If targeted therapy has to be used.

However, these changes apply to only a few selected states in the US.

Currently, Medicare does not provide coverage for any genetic testing, if a person is not having any personal history of cancer.

Medicare is a federal health insurance program. It has made very stringent changes to its previous provisions for genetic testing for breast cancer. If one has a personal history of cancer, then Medicare approves for one’s genetic testing. Otherwise at present, Medicare does not provide any coverage for the genetic testing of people without a personal history of cancer.

Pramod Kerkar, M.D., FFARCSI, DA
Pramod Kerkar, M.D., FFARCSI, DA
Written, Edited or Reviewed By: Pramod Kerkar, M.D., FFARCSI, DA Pain Assist Inc. This article does not provide medical advice. See disclaimer
Last Modified On:May 23, 2019

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