Medicare Adds Benefit for Members with Inherited Ovarian or Breast Cancer

Nov. 25, 2020

The Centers for Medicare & Medicaid Services (CMS) added a benefit this year for Medicare members with germline or inherited ovarian or breast cancer. The benefit covers a laboratory diagnostic test using Next Generation Sequencing (NGS). These tests provide genetic analysis of a patient's cancer.

What is covered

  • For services performed on or after Jan. 27, 2020, Medicare covers NGS when:
  • Performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory
  • Ordered by a treating physician
  • And the patient has all the following:
    • Ovarian or breast cancer
    • A clinical indication for germline testing for hereditary breast or ovarian cancer
    • A risk factor for germline breast or ovarian cancer
    • Has not been previously tested with the same germline test using NGS for the same germline genetic content

For more information, see CMS' national coverage determination on NGS .

Check eligibility and benefits

Use the Availity® Provider Portal or your preferred web vendor to check eligibility and benefits for all patients before providing services. This step will help you confirm coverage and other important details, such as prior authorization requirements.

Checking eligibility and/or benefit information and/or the fact that a service has been preauthorized/pre-notified is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member's eligibility and the terms of the member's certificate of coverage applicable on the date services were rendered. If you have any questions, call the number on the member's ID card.

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