Medicare Coverage For Next
Multigene panels that rely on next-generation sequencing are increasingly used to test for hereditary cancer risk-related mutations. The federal government aims to expand Medicare coverage for these tests.
by Ashley P. Taylor
Medicare will cover next-generation sequencing tests for people with any stage of female breast or ovarian cancer to determine if they have hereditary cancer-associated mutations, according to a Jan. 27, 2020, from the Centers for Medicare & Medicaid Services . To qualify, a patient must have certain risk factors and a health history that indicate heightened likelihood of having a hereditary mutation.
The sequencing test, often referred to as a multigene panel, must have approval or clearance from the Food and Drug Administration . No NGS test for hereditary mutations has been authorized by the FDA yet, the agency confirmed to Cancer Today. These tests are currently being sold as laboratory-developed tests, which are performed in the same laboratory in which they were developed and manufactured and are generally not regulated by the FDA.
Expanded coverage for NGS testing is absolutely a good idea, says Melissa Frey, a gynecologic oncologist at Weill Cornell Medicine in New York City. NGS testing for cancer patients can find mutations tremendous clinical implications.
Why Is Genetic Testing Important?
Is NGS Necessary?
Practical Questions and Current Practices
Ashley P. Taylor is a writer and science journalist based in New York City.
Catecholaminergic Polymorphic Ventricular Tachycardia
Catecholaminergic polymorphic ventricular tachycardia is a highly lethal form of inherited arrhythmogenic disease characterized by adrenergically mediated polymorphic ventricular tachycardia . Mutations in the cardiac ryanodine receptor gene and the cardiac calsequestrin gene are responsible for the autosomal dominant and recessive variants of CPVT, respectively. The clinical presentation encompasses exercise- or emotion-induced syncopal events and a distinctive pattern of reproducible, stress-related, bi-directional ventricular tachycardia in the absence of both structural heart disease and a prolonged QT interval.
CPVT typically begins in childhood or adolescence. The mortality rate in untreated individuals is 30 to 50 % by age 40 years. Clinical evaluation by exercise stress testing and Holter monitoring and genetic screening can facilitate early diagnosis. Beta-blockers are the most effective drugs for controlling arrhythmias in CPVT patients, yet about 30 % of patients with CPVT still experience cardiac arrhythmias on beta-blockers and eventually require an implantable cardioverter defibrillator. Liu et al stated that molecular genetic screening of the genes encoding the cardiac RyR2 and CASQ2 is critical to confirm uncertain diagnosis of CPVT.
The 2006 guidelines from the American College of Cardiology on management of patients with ventricular arrhythmias and the prevention of sudden cardiac death included the following recommendations for patients with CPVT:
Medicare Advantage Plans Cover Breast Cancer Treatments And Screenings
Medicare Advantage plans are required to offer all of the same benefits that are covered by Original Medicare, combined into a single plan.
This means that the breast cancer screenings, treatments and drugs listed above are covered by Medicare Advantage plans in the same way that they are covered by Medicare Part A and Part B.
Some Medicare Advantage plans may also offer coverage for potentially more breast cancer drug costs than what Original Medicare covers.
Two out of every three cases of invasive breast cancer occur in women over the age of 55.1 And breast cancer accounts for the second-highest number of cancer-related deaths for U.S. women, behind only lung cancer.2
Dont let your breast cancer screenings and treatment go without adequate medical attention and insurance coverage.
If you want to learn more about how a Medicare Advantage plan could help offer the benefits you need, call to speak with a licensed insurance agent today or compare plans online, with no obligation to enroll.
Find Medicare Advantage plans in your area
Or call 1-800-557-6059TTY Users: 711 to speak with a licensed insurance agent. We accept calls 24/7!
About the author
Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles hes written, helping Americans better understand their health insurance and Medicare coverage.
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Does Medicare Cover Mastectomy Surgery
Medicare covers mastectomy and reconstruction surgery to treat breast cancer. How much you pay for surgery depends on many factors, including where the procedure takes place. Medicare also pays for some post-mastectomy supplies, including mastectomy bras and breast prostheses.
Our fact-checking process starts with vetting all sources to ensure they are authoritative and relevant. Then we verify the facts with original reports published by those sources, or we confirm the facts with qualified experts. For full transparency, we clearly identify our sources in a list at the bottom of each page.
APAChristian, R. . Does Medicare Cover Mastectomy Surgery? RetireGuide.com. Retrieved January 27, 2022, from https://www.retireguide.com/medicare/coverage/conditions-and-treatments/mastectomy/
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Key Principles
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Whos Eligible For The Breast Cancer Index Test
You may be eligible for the Breast Cancer Index test if:
- you were diagnosed with early-stage breast cancer
- the cancer was hormone-receptor-positive
- there was no cancer in your lymph nodes or the cancer is lymph-node positive and is in one, two, or three lymph nodes
- youve been taking hormonal therapy for 4 to 5 years and want to know if taking hormonal therapy for more time will be beneficial
Research has shown that extending hormonal therapy for 5 more years for a total of 10 years of hormonal therapy can offer benefits for some women diagnosed with early-stage, hormone-receptor-positive disease.
The Breast Cancer Index test is performed on preserved tissue that was removed during the original biopsy or surgery.
Because many women have troubling side effects, including hot flashes and joint pain, from hormonal therapy, they want to know if extending the time they take hormonal therapy is worth tolerating the side effects.
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Senate Bill Proposes To Expand Medicare Coverage For Hereditary Cancer Testing
NEW YORK A new bill in front of the US Congress proposes an expansion of Medicare coverage for genomic testing and certain follow-up services in individuals with a family history of hereditary cancer.
Sponsored in the Senate by Senators Ben Cardin and Lisa Murkowski , the Reducing Hereditary Cancer Act joins a counterpart initially introduced in the House of Representatives last June by a group led by Rep. Debbie Wasserman Schultz.
âEarly detection can be the difference between life and death with a cancer diagnosis,â Senator Cardin said in a statement. âMedicareâs current restriction on genetic testing for hereditary cancers is out of step with the current science and practice. We have an obligation to ensure individuals with a family risk of cancer have access to key cancer screenings that give individuals a competitive edge in the fight of their lives.â
If passed, the bill would amend title XVIII of the Social Security Act such that it mandates Medicare coverage for germline mutation testing in individuals with a known, hereditary cancer gene mutation in their family or a history otherwise suspicious for hereditary cancer. This would be limited to once per individual.
For patients who are found to have a hereditary cancer mutation, coverage would also be guaranteed for risk-reducing surgeries as endorsed by evidence-based guidelines.
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Mitochondrial Recessive Ataxia Syndrome
Gramstad et al noted that mutations in the catalytic subunit of polymerase gamma produce a wide variety of neurological disorders including a progressive ataxic syndrome with epilepsy: mitochondrial SCA and epilepsy . The authors earlier studies of patients with this syndrome raised the possibility of more prominent right than left hemisphere dysfunction. To investigate this in more detail, 8 patients were studied. All completed an intelligence test , and 4 were also given memory tests and a comprehensive neuropsychological test battery. Patients with MSCAE showed significant cognitive dysfunction. Mean Verbal IQ was significantly better than Performance IQ , but memory testing and neuropsychological testing failed to detect a consistent unilateral dysfunction. The authors concluded that further studies are needed to define the profile and development of cognitive symptoms in this disorder.
Furthermore, UpToDate reviews on Overview of the hereditary ataxias and The spinocerebellar ataxias do not mention the use of POLG1 genetic testing.
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Does Medicaid Cover Genetic Testing For Lynch Syndrome
The majority of states cover testing for a Lynch syndrome mutation for qualifying individuals, including people with a known genetic mutation in the family, or specific personal and/or family history of cancer. As of 2020, the following Medicaid programs did not cover genetic counseling or testing
What Is The Brca1 Gene Test
Germline genetic testing of BRCA1 and BRCA2 is available to identify individuals at increased risk for breast and ovarian cancers, as individuals with an inherited cancer syndrome may benefit from screening and prevention strategies to reduce their risk. 1,20 The prevalence of BRCA mutations in the population is estimated between 1 in 300 and 1 in 800 however, specific mutations known as founder mutations occur more often in populations founded by a small ancestral group, including Ashkenazi Jews, French Canadians, and Icelanders. The prevalence of BRCA mutations in the Ashkenazi Jewish population is approximately 1 in 40. 12,17,1,20 Three recurrent BRCA1 and BRCA2 mutations have been identified in Ashkenazi Jewish individuals and make up the vast majority of BRCA mutations that occur in this population. 12,17
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Where Can You Get A Breast Form
You can find breast forms at most surgical supply stores and lingerie storesand even the lingerie departments of some department stores. Breast forms can also be purchased over the Internet.
Most experts recommend getting the help of a trained fitter. When you go for a fitting, wear a close-fitting top so that you can really see how the breast form looks and moves.
Take a partner or good friend with you for a second opinion and support.
Current as of: September 8, 2021
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Does Medicaid Cover Genetic Testing For Breast Cancer
Medicaid covers genetic testing for breast cancer in all states except three. Those three states are:
These three states do not cover the cost of genetic testing for hereditary cancer risk.
Multigene panel testing is not covered by most Medicaid programs.
Despite Medicaid covering breast cancer genetic testing cost more than Medicare and many health insurance providers, there is still a testing eligibility criteria. This eligibility criterion does differ by state. Genetic counselors help people understand if they meet the Medicaid guidelines for genetic testing in their state.
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How Should You Dress After A Mastectomy
Loose Clothing
After a mastectomy, your body is going to be very tender. During this time, it is best to keep fabric from rubbing against your sensitive skin by opting for looser clothing. Shirts with a dropped sleeve are especially helpful, as you wont experience any chaffing along the side of your breast or armpit.
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Hcpcs Codes Covered If Selection Criteria Are Met:
S3840 DNA analysis for germline mutations of the RET proto-oncogene for susceptibility to multiple endocrine neoplasia type 2 S3841 Genetic testing for von Hippel-Lindau disease S3844 DNA analysis of the connexin 26 gene for susceptibility to congenital, profound deafness S3845 Genetic testing for hemoglobin E beta-thalassemia S3850 Genetic testing for sickle cell anemia S3853 Genetic testing for myotonic muscular dystrophy S3866 Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy in an individual with a known HCM mutation in the family
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Medicare Advantage Plans May Offer Additional Benefits
Medicare Advantage plans are sold by private insurance companies and are an alternative to Original Medicare. Medicare Advantage plans cover the same benefits that are covered by Original Medicare.
If your genetic test is covered by Original Medicare, it will also be covered by a Medicare Advantage plan.
Many Medicare Advantage plans may offer prescription drug coverage. Some plans may also offer coverage for routine dental, hearing and vision care, as well as some other benefits.
A licensed insurance agent can help you compare available Medicare Advantage plans in your area. Call to speak with an agent today to learn if youre eligible to enroll and find a plan that fits your needs.
Compare Medicare Advantage plans in your area
Or call 1-800-557-6059TTY Users: 711 to speak with a licensed insurance agent. We accept calls 24/7!
About the author
Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles hes written, helping Americans better understand their health insurance and Medicare coverage.
Christians work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.
A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelors degree in journalism.
What Are The Next Steps After Brca Gene Testing
Once youve taken a BRCA gene test, there are three possible test results you can receive:
- Positive. A positive result indicates the presence of a harmful BRCA1 or BRCA2 variant, which places you at an increased risk of developing breast, ovarian, or other cancers.
- Negative. A negative result indicates one of two things: 1) that you did not inherit a harmful BRCA1 or BRCA2 variant from a close family member, or 2) that you do not have the specific variant tested for but may possibly have another variant.
- Variant of uncertain significance . A VUS result indicates the presence of another genetic variant that is rare but not currently associated with an increased risk of cancer.
Depending on your test results, your doctor or genetic counselor will advise you on the next steps. If you have tested positive for BRCA1 or BRCA2 variants, there are many ways that you can reduce your cancer risk, including annual screenings, certain medications, and preventative surgeries.
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Does Medicare Cover Cancer
Depending on your specific cancer and circumstances, your doctors will work together to develop a treatment plan for you that meets your needs. Medicare helps cover the services, tests and items you may need for your cancer treatment. Typically, these may include surgery, chemotherapy, immunotherapy and/or other treatments, which would be covered either under Part A, Part B or Part D.
Cpt Codes Covered If Selection Criteria Are Met:
0237U Cardiac ion channelopathies , genomic sequence analysis panel including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions 81413 Cardiac ion channelopathies genomic sequence analysis panel, must include sequencing of at least 10 genes, including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A 81414 Cardiac ion channelopathies duplication/deletion gene analysis panel, must include analysis of at least 2 genes, including KCNH2 and KCNQ1
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Genetic Testing All Women For Breast Cancer Might Not Be Worth The Cost
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Illustration: Centers for Disease Control and Prevention National Cancer Institute |
Women who are carriers of mutated BRCA genes are known to have a significantly higher risk for developing breast and ovarian cancers than those who dont. But a new UCLA study questions the value of screening for the genetic mutations in the general population including those who do not have cancer or have no family history of the disease because of the high cost. The UCLA researchers found that compared with universal screening, other diagnostic tools remain more efficient and might be more cost-effective.
The researchers concluded the BRCA genetic test that is most widely used today, which costs about $4,000, is too expensive to warrant universal screening, given how rare BRCA mutations are. The cost of BRCA testing would need to drop by 90 percent for testing to be cost-effective for the whole population, says Patricia Ganz, MD73 , director of the Division of Cancer Prevention and Control Research at UCLAs Jonsson Comprehensive Cancer Center.
Harmful BRCA gene mutations are more likely to be found in families affected by breast and ovarian cancers, and carriers can pass the mutated genes to both daughters and sons. Those who carry a BRCA mutation are thought to have a 45-to-80-percent lifetime risk of developing breast cancer. Women carrying the BRCA-1 mutation have up to a 39-percent lifetime risk women with BRCA-2 have a 10-to-17-percent lifetime risk for ovarian cancer.
Inherited Gene Mutations That Increase Breast Cancer Risk
Most women who get breast cancer dont have an inherited gene mutation.
In the U.S., 5-10 percent of breast cancers are linked to an inherited gene mutation . About half of these breast cancers are linked to a BRCA1 or BRCA2 gene mutation .
The lifetime risk of breast cancer is increased 20-49 percent for women with moderate-risk inherited gene mutations and 50 percent or more for women with high-risk inherited gene mutations.
Inherited mutations in any of these genes can increase the risk of breast cancer:
Most of these gene mutations also increase the risk of other cancers.
BRCA1/2 gene mutations are the most well-known of these high-risk gene mutations. The others are less common and theres still much to learn about them. Most dont increase the risk of breast cancer as much as BRCA1/2 gene mutations do.
Some inherited gene mutations have only recently been shown to increase the risk of breast cancer. Data on these mutations and their related cancer risks are still emerging and will likely change over time.
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