The Medicare Way
While the guidelines under private coverage may be solid, the same can not be said of Medicare or Medicaid.
Medicare does not have a local or national coverage decision for BRCA testing and instead relies on a patchwork of policies that may be implemented at the discretion of local contractors, according to a spokesperson for the Centers for Medicare & Medicaid Services. I was told, "…as for BRCA tests, they really are not local options for screening. Local contractors may cover them for diagnosis or to guide treatment only."
The prophylactic mastectomy is classified as a preventive surgery and is "generally not covered whether at the local or national level," the CMS spokesperson explained.
But isn't healthcare reform supposed to be largely about prevention? The Patient Protection and Affordable Care Act includes a list of preventive services that it expects private insurers to cover without a co-pay or deductible. According to FORCE, an advocacy group for cancer patients, HHS has clarified that genetic counseling for inherited breast and ovarian cancer risk and BRCA testing fall under this policy.
Granted, the PPACA applies to private insurers and not to Medicare, but the clarification seems to confirm the importance of BRCA testing. Still, CMS tells me that the agency is not contemplating a national coverage decision for BRCA tests for screening or mastectomies for prevention.