Next Generation Sequencing Tests For Cancer Patients
Medicare first began covering laboratory diagnostic tests using next generation sequencing in 2018. Only Medicare beneficiaries with advanced cancer that met specific criteria qualified for coverage.
Next generation sequencing is a test that analyzes a patients genetic makeup in order to pursue more targeted treatments and medications.
According to the U.S. Center for Medicare & Medicaid Services, NGS testing provides the most comprehensive genetic analysis of a patients cancer because it can detect multiple types of genetic alterations at the same time.
These tests are meant to help patients and their oncologists make more informed treatment decisions.
The NGS test, also known as a multigene panel, can help identify beneficiaries who qualify for clinical trials.
Medicare will cover next generation sequencing if you have:
- Recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer
- Not been previously tested using NGS for the same cancer and genetic content
Clinical laboratory tests are covered under Medicare Part B. You usually pay nothing for Medicare-approved clinical diagnostic laboratory services.
Medicare Coverage And Genetic Testing For Cancer
Medicare beneficiaries who need genetic counseling can get it covered under Medicare Part A and Part B only if it has been ordered by a physician before starting medication covered under Part D or if it is medically necessary in a skilled nursing facility.
Medicare covers certain genetic cancer tests if theyre medically necessary. In 2020, Medicare will cover genetic testing if:
- You have recurring, relapsed, refractory, metastatic, or advanced stage III or IV cancer
- You have not used the same genetic test for the same cancer diagnosis previously
- You have decided to seek further cancer treatment such as chemotherapy and radiation
- You have signs or symptoms of a cancer like colorectal cancer that can be clarified or verified with diagnostic testing
- You have a first-degree relative who has a known mutation such as Lynch syndrome
Genetic Testing Coverage & Reimbursement
Most health insurance plans will cover the cost of genetic testing when recommended by a physician. However, all coverage and reimbursement is subject to Medicare, Medicaid, and third-party payer benefit plans. Therefore, ASCO strongly encourages you to verify with the patients insurer to understand what type of services will be covered.
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Risk Factors For Hereditary Cancer
When cancers are linked to an inherited gene mutation, thats called a family cancer syndrome.
Certain factors may make it more likely that you and your family members can pass cancer on to your loved ones including:
- Many cases of the same kind of cancer like ovarian cancer caused by BRCA1 and BRCA2 gene mutations
- Cancers that occur much sooner than usual like breast cancer in a teenager
- One person who has multiple types of cancer
- Cancers that occur in pairs of organs
- Siblings who have childhood cancers
- Cancer that occurs in the opposite sex of the one usually affected
- Cancer that occurs in several generations
We Can Help You Find The Best Medicare Plans For Cancer Patients
A Medicare Advantage plan is a great option if you are looking for additional benefits like genetic testing beyond BRCA 1 and 2 and myPath.
Some may even offer fitness classes like SilverSneakers®, which can help promote a healthy, physically active lifestyle and help lower your risk of cancer.
If youre diagnosed with cancer, you may be eligible for a type of MA plan called a Chronic Special Needs Plan . These plans are specially designed for people with certain chronic illnesses and conditions. Your C-SNP will involve a network of healthcare providers that will coordinate your treatment plan with each other.
If you are interested in arranging a no-cost, no-obligation appointment with a licensed agent to discuss your options for MA plans including C-SNPs, call us at 833-438-3676 or fill out this form.
This post was originally published on November 29, 2018, by Kelsey Davis and updated on March 24, 2020, by Troy Frink.
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Mammogram For Breast Cancer Screening
All women 40 years old and older are covered for one mammogram screening every 12 months under Medicare Part B. If youre between the age 35 and 39 and on Medicare, one baseline mammogram is covered.
If your doctor accepts the assignment, these tests will not cost you anything. Accepting the assignment means that your doctor agrees that they will accept the Medicare-approved amount for the test as full payment.
If your doctor determines that your screenings are medically necessary, diagnostic mammograms are covered by Medicare Part B. The Part B deductible applies, and Medicare will pay 80 percent of the approved amount.
- multi-target stool DNA lab tests
Keep reading for more information on each screening.
Reviewed And Updated By Drew Gurley Consumer Strategy
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Cancer is the leading cause of death worldwide and impacts millions of patients and families each year. Fortunately, genetic testing for cancer, which is growing in popularity, can be a great tool for understanding your risk of developing cancer.
Does insurance pay for genetic testing of cancer? Yes, but coverage determination depends on certain circumstances.
The Food and Drug Administration and the Centers for Medicare and Medicaid Services , are actively working to make sure these tools are effective and accessible.
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Reducing Hereditary Cancer Act Promises To Expand Access To Cancer Screenings And Interventions For High
Bipartisan legislation will remedy outdated policy to facilitate cancer prevention and early detection, aligning genetic risk assessment and related health services with guideline-recommended care
Newswise Washington DC Yesterday, United States Senators Ben Cardin and Lisa Murkowski introduced the Reducing Hereditary Cancer Act, bipartisan legislation to expand access to medically-appropriate genetic testing to determine an individuals risk of developing hereditary cancerand access to evidence-based medical care to reduce risk for those who have a predisposing genetic mutation. The Senate bill is identical to H.R. 4110, introduced in the House in June of 2021.
Medicare currently covers genetic testing only for people who have already been diagnosed with cancer, regardless of a history of cancer or known genetic mutations in their family. It does not cover medically necessary cancer screenings or risk-reducing interventions for individuals who have a genetic mutation increasing their cancer risk.
FORCE: Facing Our Risk of Cancer Empowered and the National Comprehensive Cancer Network® are proud to advocate for this legislation that would remedy a longstanding Medicare gap, ensuring that beneficiaries at increased risk of cancer have access to standard-of-care genetic counseling, testing, screening, and risk-reducing interventions.
Resources:
Medicare Coverage Of Cologuard A Genetic Screening Test
Since 2014, Medicare Part B has covered Cologuard, a genetic test used to screen for colorectal cancer.
Cologuard tests fecal DNA in a stool sample to detect signs called molecular markers or biomarkers of altered DNA shed into the stool from colon cancer or small growths in the colon, called polyps.
Cologuard is the only genetic screening preventative test i.e., a test to detect indicators of potential disease as opposed to the presence of a disease Medicare covers.
Medicare covers Cologuard once every three years for beneficiaries between ages 50 and 85 who have no symptoms of colorectal cancer and are at an average risk for developing it.
Just like other Medicare-covered preventive services, Part B pays 100 percent of the approved amount for Cologuard for those who qualify.
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Genetic Testing And Medicare Advantage
Medicare Advantage plan benefits may differ. Many Medicare Advantage plans offer additional benefits on top of those provided by Original Medicare coverage, but because each plan and provider are unique, you will need to consult with your plan manager for more details as to what services are covered.
Some Medicare Advantage plans may provide access to a wider range of genetic testing resources compared to Original Medicare coverage, and you may also face fewer restrictions or have to meet fewer obligations in order to receive coverage for testing.
TIP: Discover the top 7 reasons to switch your Medicare Advantage plan.
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Medicare Coverage For Genetic Testing
In general, Medicare insurance does not cover genetic testing however, there are some circumstances in which the program will cover genetic testing for breast cancer as long as you have met certain requirements, including having a personal or family history of breast cancer.
If covered under Original Medicare, genetic testing benefits will be provided by Medicare Part B for any services rendered through your doctors office or a lab. If testing is conducted while you are admitted to a hospital or skilled nursing facility, Medicare Part A would likely apply instead.
TIP: Are you ready to get the most out of Medicare? Head on over to our Medicare basics guide.
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Does Medicare Cover Counseling With 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.
What Are My Chances Of Getting Cancer
The American Cancer Society estimates that 1 in 3 people in the United States will develop cancer at some point in their life. Data and research show that cancer risk is highest for those between the ages of 65 to 74 years and accounts for the largest portion of new cancer cases found each year.
While you may have a smaller chance of developing cancer if you are under the age of 65, it is still a good idea to get tested as early as possible so that you can make smart decisions about health insurance and your future.
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Pharmacogenomics And Other Genetic Tests
Since 1998, Medicare has covered cytogenetic studies in specific situations.
Cytogenetics involves testing samples of tissue, blood or bone marrow in a lab to identify changes in chromosomes.
Medicare covers these tests when they are necessary for the diagnosis or treatment of certain kinds of leukemia and rare blood cancers.
Cytogenetic studies may also be covered when they are used to diagnose or treat genetic disorders in a fetus or failure of sexual development.
Lynch Syndrome Genetic Testing
Hereditary nonpolyposis colorectal cancer is the most common hereditary form of CRC. It is also a very pernicious formpolyps can progress to the cancerous state in just 30 months, compared to 10 or more years for other CRC polyps . Accordingly, the NCCN High-Risk Assessment Guidelines address Lynch syndrome evaluation criteria and testing strategies . Healthy People 2030 lists increasing the proportion of people with CRC who are tested for LS as a research objective and high-priority public health issue . The Centers for Disease Control and Prevention consider HBOC and LS as Tier 1 conditions, applications for which the base of collected evidence on clinical validity and utility supports implementation into practice . The Evaluation of Genomic Applications in Practice and Prevention Working Group found sufficient evidence to recommend offering genetic testing for LS to all individuals with newly diagnosed CRC . However, because they are prevention-oriented and focused on the general population, the USPSTF recommendations apply only to asymptomatic adults 45 years or older who are at average risk of colorectal cancer, excluding individuals who are at a high lifetime risk, such as for Lynch syndrome and familial adenomatous polyposis . This omission is based on mission definition rather than level of evidence, and does not preclude the value gained from conducting LS genetic testing and screening in those at risk.
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Does Insurance Cover Brca Testing
In the United States, BRCA testing is usually covered by insurance if the patient meets certain criteria. Insurance coverage and criteria varies by insurance plan, and genetic counselors will review potential costs and insurance coverage with you during your appointment.
Some insurance companies have specific testing criteria or do not cover testing in certain situations, even when it is considered medically appropriate. For example, Medicare has specific BRCA testing criteria that only includes individuals with a personal history of cancer. Therefore, Medicare does not cover someone with a known mutation in the family who has no personal history of cancer. Medicaid coverage typically varies by state.
Hereditary Breast And Ovarian Cancer Genetic Testing
Hereditary breast and ovarian cancer associated with BRCA1 and BRCA2 mutations is the most common form of hereditary breast cancer. A 2015 population-based study of 396 African American women diagnosed with breast cancer before age 50 found that 12% of the study participants had BRCA1/2 mutations, more than double what was found in white women .
In 2005, the USPSTF recommended that women whose family history may be associated with an increased risk for deleterious BRCA1/2 mutations be referred for genetic counseling and evaluation for BRCA testing . Through time, the Centers for Medicare and Medicaid Services and other federal health agencies have issued clarifications broadening the criteria for coverage .
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Does Medicare Cover Genetic Testing For Melanoma
Medicare currently covers the Myriad Genetics myPath and Castle Biosciences DecisionDx genetic tests for melanoma.
Medicare also covers screenings for lung, breast, prostate, and cervical cancer. Screenings are used to detect potential disease and a diagnostic test establishes the presence or absence of the disease.
Senate Bill Proposes To Expand Medicare Coverage For Hereditary Cancer Testing
NEW YORK A new bill in front of the US Congress proposes an expansion of Medicare coverage for genomic testing and certain follow-up services in individuals with a family history of hereditary cancer.
Sponsored in the Senate by Senators Ben Cardin and Lisa Murkowski , the Reducing Hereditary Cancer Act joins a counterpart initially introduced in the House of Representatives last June by a group led by Rep. Debbie Wasserman Schultz.
“Early detection can be the difference between life and death with a cancer diagnosis,” Senator Cardin said in a statement. “Medicare’s current restriction on genetic testing for hereditary cancers is out of step with the current science and practice. We have an obligation to ensure individuals with a family risk of cancer have access to key cancer screenings that give individuals a competitive edge in the fight of their lives.”
If passed, the bill would amend title XVIII of the Social Security Act such that it mandates Medicare coverage for germline mutation testing in individuals with a known, hereditary cancer gene mutation in their family or a history otherwise suspicious for hereditary cancer. This would be limited to once per individual.
For patients who are found to have a hereditary cancer mutation, coverage would also be guaranteed for risk-reducing surgeries as endorsed by evidence-based guidelines.
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Will A Positive Genetic Test Result Make It Harder For Me To Get Health Insurance
Some people have worried that genetic testing for future health risks could affect their ability to get or keep their health insurance. Fortunately, a federal law called the Genetic Information and Nondiscrimination Act, or GINA, was passed in 2008 and enacted in May 2009 and works together with pre-existing nondiscrimination laws such as the Health Insurance Portability and Accountability Act .
GINA generally forbids health insurers or health plan administrators from using genetic test results for decisions regarding coverage or rates health insurance companies cannot consider genetic testing results as a preexisting condition. GINA also protects the individual from hiring, firing, or promotional decisions in the workplace based on genetic information. There is also additional protection available under individual states laws and through the Affordable Care Act.
Breast Cancer Genetic Testing & The Brca Testing Cost
It is easy to learn your genetic risk of the most common hereditary cancers, including BRCA 1 and BRCA 2 genes. BRCA stands for BReast CAncer genes. BRCA 1 is on chromosome 17 and BRCA 2 is on chromosome 13.
All it takes is a small DNA sample through saliva.
Plus, the test can be conveniently mailed to you and completed in the comfort of your home. The cost of a hereditary cancer testing kit can range from $100 to $200.
There are multiple genetic testing companies, including Color and 23andMe, but not all are approved by the FDA.
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