BRCA1 and BRCA2 Genetic Testing

Medically necessary BRCA1/BRCA2 testing is covered for adults with personal histories of breast (with defined age/family-history/phenotype criteria), ovarian/fallopian tube/primary peritoneal cancer, male breast, pancreatic, or prostate cancer (Gleason ≥7), for testing of known familial mutations in symptomatic individuals, and for Ashkenazi Jewish individuals using founder-mutation first testing. Multigene NGS panels may be covered when NCD 90.2 and additional counseling, gene-relevance, and multiple-syndrome criteria are met. Testing is limited to once per lifetime, is not covered for asymptomatic individuals or population screening (including most unaffected relatives), and is not covered for persons under age 18; documentation of genetic counseling and medical necessity is required.

"BRCA1/BRCA2 testing is covered for adults with a personal history of invasive breast cancer or ductal carcinoma in situ diagnosed at age 45 or younger."