I'm considering genetic testing to assess my cancer risk based on family history. Will Medicare cover this preventive approach in my situation?

Question

Larry Dalton · Accepted Answer

Under traditional Medicare Part A and B with a Medigap plan, Medicare generally does not cover pre-symptomatic genetic testing for cancer risk assessment.  However, with a doctor's order for the testing, it will most likely be approved for certain types of cancer testing.  Some Medigap plans come with a rider that covers 100 percent of preventive care testing.   

Under the Medicare Advantage plan, these tests most likely will require prior approval from the insurance company.

Clarence &quot;Mark&quot; Christiansen · Answer

Check with your health care team on this one but yes, generally speaking Medicare covers genetic testing if it's deemed "medically necessary." If the test you want is based on family history, your chances are good that Medicare will approve it.

Answered by Clarence "Mark" Christiansen on April 4, 2025

Agent Licensed in WI, AZ, CA & 16 other states

Answered by Clarence "Mark" Christiansen Medicare Insurance Agent

Michael Denniston · Answer

Medicare will cover genetic testing if a beneficiary is having symptoms of chronic illnesses or is at a genetic risk to get a chronic illness or disease. Should be requested by your doctor.

Deborah Lee · Answer

Does Medicare cover gentic testing for cancer?


ChatGPT said:
Yes, Medicare may cover genetic testing for cancer, but only under certain conditions. Coverage typically depends on the specific test, the medical necessity, and whether the test is ordered by a qualified healthcare provider.

Medicare Coverage Criteria for Genetic Testing (Cancer)
Medicare may cover genetic testing for cancer if:

You have a personal history of cancer, such as breast, ovarian, colorectal, or prostate cancer.

The test is medically necessary—usually to guide treatment or assess hereditary cancer risk.

The test is ordered by your doctor and performed in a Medicare-approved laboratory.

You meet specific criteria for certain tests. For example:

BRCA1 and BRCA2 testing (for breast/ovarian cancer) may be covered if you have a personal history of cancer and meet other risk factors.

Lynch Syndrome testing (for colorectal cancer) may be covered if you meet clinical criteria.

Important Notes
Medicare does not cover genetic testing for screening or curiosity purposes.

Testing based on family history alone, without a personal cancer diagnosis, is typically not covered.

Medicare Advantage (Part C) plans may have additional coverage or requirements.

What You Should Do
Talk with your doctor or a genetic counselor about whether you qualify.

Make sure any testing is ordered by your physician and performed by a CLIA-certified lab that accepts Medicare.

Check with your plan or Medicare directly (1-800-MEDICARE) to confirm coverage for your specific situation.

James ONeal · Answer

Generally, Medicare does not cover genetic testing as a routine screening test to assess your risk of developing cancer based solely on family history if you do not have symptoms or a personal history of the specific cancer being tested for.  

However, there are specific situations where Medicare may cover genetic testing for hereditary cancer syndromes, including:

You have a personal history of a specific cancer: 

Medicare may cover genetic testing if you've already been diagnosed with certain cancers, such as breast or ovarian cancer, and meet specific criteria related to age of diagnosis, family history, or tumor characteristics.

Steven Bleicher · Answer

It depends on how the doctor codes the visit. However, the odds are that this decision is based on your own choice with nothing having to do with any health issues that you posed to your doctors.

Yasmery Vargas · Answer

Unfortunately, there are requirements that must be met and a physician must confirm it is medically necessary. In most cases the question is best asked directly to your Healthcare provider and/or your specific insurance company to see if there are accommodations for your particular situation.

Answered by Yasmery Vargas on April 15, 2025

Agent Licensed in PA

Answered by Yasmery Vargas Medicare Insurance Agent

Glenn Quinn · Answer

Generally, Medicare does not cover preventive genetic testing or testing to detect undiagnosed diseases or predispositions. However, Medicare Part B may cover genetic testing for certain conditions, like diagnosing inherited disorders or guiding medical treatment decisions, if ordered by a physician and deemed medically necessary. For example, genetic testing for specific cancer risks or to determine how a person may respond to specific medications might be covered.

Answered by Glenn Quinn on April 20, 2025

Broker Licensed in FL, AL, AR & 13 other states

Answered by Glenn Quinn Medicare Insurance Agent

John Zentner · Answer

Medicare can cover genetic testing to assess cancer risk based on family history, especially for individuals with a known issues in their family or who meet specific criteria for hereditary cancer risk assessment. However, Medicare generally doesn't cover genetic testing for pre-symptomatic screening or to simply determine an individual's risk of developing an inherited condition. It is always best to check your plan first to make sure there are no hidden cost surprises.

Answered by John Zentner on April 28, 2025

Agent Licensed in CA

Answered by John Zentner Medicare Insurance Agent

Fred Manas · Answer

Medicare may cover genetic testing for cancer risk assessment if it's deemed medically necessary, based on your family history and specific criteria. However, coverage isn't automatic and depends on factors like the type of cancer, your age, and the specific genes being tested. 
Here's a more detailed breakdown:
Medicare's general stance:
.
Medicare generally covers genetic testing when it's deemed medically necessary to diagnose or treat a condition. 
Cancer-related genetic testing:
.
Medicare may cover genetic testing for certain cancers, particularly if you have a personal history of cancer, a family history of cancer, or other risk factors like being of Ashkenazi Jewish descent. 
BRCA gene testing:
.
Testing for BRCA1 and BRCA2 mutations (which are linked to increased breast and ovarian cancer risk) may be covered under specific circumstances, such as a personal history of breast cancer before age 60, a family history of relevant cancers, or being of Ashkenazi Jewish descent. 
Other factors:
.
Medicare also considers the severity of your condition, the evidence supporting the link between genes and cancer, and whether the test results will impact your treatment plan. 
Medical necessity is key:
.
To be covered, the genetic testing must be ordered by a physician and deemed medically necessary based on your individual circumstances. 
Check with your doctor and insurer:
.
It's essential to discuss your specific situation with your doctor and your insurance provider to determine if your planned genetic testing is likely to be covered by Medicare and what your out-of-pocket costs might be. 
In short, while Medicare may cover genetic testing for cancer risk assessment in some cases, it's not a blanket policy. Discuss your specific situation with your doctor and insurance provider to get a clear understanding of coverage and costs.

Gary Henderson · Answer

Medicare typically covers genetic testing that's used to diagnose or guide treatment for a specific health problem, but not to predict risk or detect undiagnosed conditions.

Suzanne Lamperti · Answer

Unfortunately thus test us NOT covered by Medicare. Although it should be, because it would help Americans take the necessary steps to avoid getting cancer.

Charles Borg · Answer

I don’t think so. There would usually have to be a diagnosis to.  be covered for a genetic test procedure.

Darko Bozic · Answer

Generally, no. Medicare might cover it if your doctor orders to help with your current treatment. If it is purely for preventive informational purposes it most likely will not be covered.

Patrick Stinson · Answer

Factors Influencing Medicare Coverage:
Clinical Indications: You need a clinical indication for germline (inherited) testing for hereditary cancer. This means your doctor must recommend it based on your specific situation and family history. 
Risk Factors: You must have risk factors for germline (inherited) cancer. 
No Prior Testing: You must not have been previously tested for the same germline genetic content. 
FDA Approval: The test must be approved by the FDA. 
Medical Necessity: The test must be medically necessary and ordered by a physician.

Gene Page · Answer

No. Genetic cancer testing is only approved once a cancer has been diagnosed. It can then be useful for the purpose of treating or mapping a course of action.