Medicare Adds Benefit for Members with Inherited Ovarian or Breast Cancer
Posted January 4, 2021
The Centers for Medicare & Medicaid Services (CMS) added a benefit in 2020 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 obtaining prior authorization or pre-notification 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, including, but not limited to, exclusions and limitations 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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The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.