Medicare typically covers genetic tests only when a beneficiary has signs or symptoms that can be further clarified by diagnostic testing. Medicare also covers some genetic tests that assess an individual’s ability to metabolize certain drugs. The only screening test Medicare will cover (once every three years) is to determine if a beneficiary has colorectal cancer. That test is appropriate when a beneficiary has no symptoms of colorectal cancer and only an average risk of developing it. Federal Regulation 42 CFR § 410.32(a) requires genetic tests to be ordered by a physician who is treating the beneficiary.
The Center for Medicare Advocacy (the Center) has heard of beneficiaries who have been approached outside of their doctor’s offices by individuals and companies seeking, inappropriately, to assure them that Medicare will pay for DNA kits and screening tests. Beneficiaries should always seek the advice and orders of their treating physician on Medicare-coverage related issues. A detailed article on Medicare coverage and oversight of genetic testing, authored by a long-time colleague of the Center, Mike Klug, can be found at https://www.smpresource.org/Handler.ashx?Item_ID=E3BA48E4-57F1-458B-B3D1-7F22FD13FF58
May 2, 2019 – K. Holt