Fortunately, Angelina Jolie Isn't On Medicare
Even signing up for a Medicare Advantage plan from a private payer could be an option for Medicare-eligible women to gain BRCA coverage. Many commercial insurers apply their BRCA and prophylactic mastectomy criteria to their Medicare Advantage plans as well despite the lack of a definitive CMS policy.
The weak link is Medicare.
As for large private payers, most not only cover BRCA and prophylactic mastectomies, they are explicit about their coverage criteria. (A word of caution: Just because coverage is offered by payers does not mean that every employer will elect to include it.)
Aetna's approach is typical. A 23-page clinical policy bulletin details the high-risk indicators that must be met to deem that testing, and then the procedure itself are medically necessary.
To develop their coverage criteria, insurers have turned to guidelines from the American College of Obstetricians and Gynecologists, the American College of Medical Genetics, and the U.S. Preventive Services Task Force among other groups and organizations. Among the high-risk indicators:
- Women diagnosed with breast cancer at 45 years of age or younger
- Two members of family diagnosed with breast cancer under age 50 or ovarian cancer at any age
- Close male blood relative with breast cancer
- Women without a personal history of breast cancer with three or more close blood relatives on the same side of the family with breast cancer.
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