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Medicare to Expand Coverage of DNA Sequencing for Patients with Ovarian or Breast Cancer

The Centers for Medicare and Medicaid Services (CMS) has announced that it will be expanding Medicare coverage of DNA sequencing for cancer patients. 

On January 27, 2020, the CMS announced its plans to add DNA sequencing coverage for patients suffering from inherited ovarian cancer or inherited breast cancer. Medicare first began covering DNA sequencing in March of 2018, but only for patients with advanced stages of cancer.

What is DNA sequencing for cancer treatment?

DNA sequencing provides a comprehensive genetic analysis of a patient’s cancer by allowing for simultaneous detection of multiple types of genetic changes.

Through DNA sequencing, doctors are able to formulate a better idea of the makeup of a patient’s cells. This in turn allows for a more targeted approach to cancer treatment.

Medicare will cover lab tests for Next Generation Sequencing (NGS) that are approved by the federal Food and Drug Administration (FDA).

How does Medicare cover genetic testing?

Medicare covers genetic testing and counseling for people who have been diagnosed with cancer and meet all of the following criteria:

  • The patient has recurrent, relapsed, refractory, metastatic or advanced stage III or stage IV cancer.

  • The patient has not been previously tested for the same cancer diagnosis using the same genetic test.

  • The patient has decided to seek further cancer treatment. 

The testing itself must meet all of the following criteria:

  • The test is approved by the FDA or has clearance as a companion diagnostic.

  • The test is accompanied by an FDA-approved drug or treatment for the patient’s type of cancer.

  • Test results are provided to the physician for management of the patient’s cancer using a report that specifies treatment options. 

“We recognize that cancer patients shoulder a heavy burden, so we’re leaving no stone unturned in supporting women’s health and getting all patients the care they need. NGS testing provides clinically valuable information to guide patients and physicians in developing a personalized treatment plan.” – CMS Administrator Seema Verma1

Do Medicare Advantage plans cover genetic testing?

Medicare Advantage plans (Medicare Part C) are sold by private insurance companies and replace your Original Medicare coverage (Part A and Part B). With a Medicare Advantage plan, you get all of the coverage benefits that are available with Original Medicare, which includes covered genetic testing and Next Generation Sequencing.

Medicare Advantage plans may also offer benefits that Original Medicare doesn’t cover. Most Medicare Advantage plans cover prescription drugs, which can include some cancer treatment drugs. Many Medicare Advantage plans may also offer benefits such as routine dental and vision coverage, hearing care coverage and non-emergency transportation, which Original Medicare doesn’t cover.

Learn more about Medicare Advantage plans that are available near you by calling to speak with a licensed insurance agent. You can also compare Medicare plans online, with no obligation to enroll.

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