Cancer genetic testing can involve changes found in a tumor or inherited changes that affect a family. These are different questions, and Medicare coverage for one test does not automatically cover the other. Start with the exact test your treating clinician proposes.
Distinguish the purpose
| Requested service | What the record should explain |
|---|---|
| Tumor-focused testing | Diagnosis, current disease context and intended clinical use. |
| Inherited-risk testing | Personal diagnosis and relevant hereditary-risk criteria. |
| Repeat testing | Prior results and whether repetition is covered. |
| Counseling visit | Who provides and bills the separate service. |
National and local rules have defined limits
CMS policy 90.2 addresses next-generation sequencing for specified acquired and inherited cancer circumstances. Its national and contractor-review pathways have different criteria. It is not general authorization for every person, laboratory panel or test marketed for cancer prevention.
The clinical team should check all requirements, including the test's status, laboratory qualifications, relevant diagnosis and prior testing. Do not substitute a commercial insurer's policy or another patient's payment history for a decision about your request.
Before the sample is sent
- Write down the test and laboratory names.
- Ask how the result will be used in your care.
- Confirm the policy and supporting records.
- Check any Medicare Advantage network or authorization rules.
- Request an estimate for the test and separate professional services.
Original Medicare-covered diagnostic laboratory tests usually have no patient charge. This does not mean every genetic panel is covered or every associated appointment is free.
If the answer is no
Obtain the written reason and review it with the treating team. Follow the appeal instructions for the actual decision. Your clinician should interpret results and explain clinical options; this page does not recommend a test or treatment.
Related coverage questions
- A Medicare Medical Claim Was Denied: What to Do Next
- Original Medicare: What Parts A and B Cover and How You Pay
- How to Compare Medicare Advantage Plans: A Practical Worksheet