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HomeExclusiveIs Genetic Testing For Breast Cancer Covered By Insurance

Is Genetic Testing For Breast Cancer Covered By Insurance

Pharmacogenetic And Pharmacodynamic Testing

Breast Cancer Genetic Testing Options & Insurance Coverage Questions

Aetna considers germline BRCA testing medically necessary for women with advanced ovarian cancer who have been treated with three or more prior lines of chemotherapy and are being considered for olaparib . Aetna considers germline BRCA testing medically necessary for women with metastatic, human epidermal growth factor receptor 2 -negative breast cancer who have previously been treated with chemotherapy in the neoadjuvant, adjuvant or metastatic setting and are being considered for olaparib . Women with hormone receptor -positive metastatic breast cancer should have been treated with a prior endocrine therapy or be considered inappropriate for endocrine treatment. Somatic BRCA testing is not medically necessary and therefore is not eligible for coverage.

Prophylactic Mastectomy For Diabetic Mastopathy

Agochukwu and Wong stated that diabetic mastopathy is a benign condition of the breast that typically manifests in patients with diabetes mellitus. Lymphocytic mastopathy is the term used to describe this condition in patients without diabetes mellitus. Most patients undergo excisional biopsy, but the use of mastectomy, even in cases of diffuse, bilateral disease, is rarely reported. These investigators presented the case of a 32-year old woman with type 1 diabetes and bilateral diabetic mastopathy. Because of pain, and concern for limitations in future cancer detection, she underwent bilateral NSM with immediate direct-to-implant reconstruction. A systematic literature review was performed to examine the therapeutic options for this disease, particularly from a plastic surgery perspective. A total of 60 articles were reviewed that contained information regarding 313 patients. Of these patients, only 4 underwent mastectomy. The authors concluded that this case was the 1st report of bilateral NSM and immediate implant reconstruction for a patient with bilateral, symptomatic diabetic mastopathy.

When Is Genetic Testing Not Likely To Be Useful

Genetic testing is unlikely to find a gene mutation that impacts risk reduction, screening or treatment in :

  • Women diagnosed with breast cancer after age 65 who dont have a close family member with breast, ovarian, pancreatic or prostate cancer
  • Men diagnosed with early stage or slow-growing prostate cancer who dont have a close family member with breast, ovarian, pancreatic or prostate cancer

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What If I Have No Insurance Or My Insurance Will Not Cover My Brca Testing

There are also options for individuals who lack insurance coverage of genetic testing.

  • Uninsured individuals may be eligible for free testing at certain laboratories.
  • If you do not meet your insurance companys BRCA coverage criteria, certain laboratories have reduced rates for individuals who are paying out of pocket.
  • The medical center where you were tested may have special charity funds. Coverage is usually considered on a case-by-case basis.

A Mother And Daughter Confront Their Breast Cancer Risk

Medicare to Cover Gene Tests in Inherited Breast, Ovarian ...

When it comes to inherited genetic mutations that increase the risk of breast cancer, BRCA1 and BRCA2 get nearly all the attention.

Inherited mutations in these genes cause from 5 to 10 percent of breast cancers as well as up to 15 percent of ovarian cancers, according to the National Cancer Institute.

There are other, rarer genetic mutations that also predispose women to breast cancer.

Health insurers that cover BRCA-related testing and treatment without a hitch sometimes balk at providing coverage in these other instances. The predictive value of some of those variations isn’t always as strong or clear-cut.

When Angelie Jolie said earlier this month that she’d tested positive for the BRCA1 mutation and had a double mastectomy to substantially reduce her risk of getting breast cancer, she didn’t mention her insurance coverage.

But many health insurance plans routinely cover genetic counseling and testing if a woman has a family history of breast or ovarian cancer. This is particularly true when there’s a pattern of early breast cancer, with diagnoses of family members in their 40s, long before the mid-60s when most women develop the disease.

Under the Affordable Care Act, health plans that weren’t grandfathered must cover genetic counseling and testing in such women without requiring them to pay anything out of pocket for it.

Counseling can cost several hundred dollars, and the genetic test costs roughly $3,000.

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Online Tools To Help You Talk With Your Health Care Provider

There are a few online tools to help you talk with your health care provider about your risk of having a BRCA1/2 inherited gene mutation and your risk of breast cancer.

Keep in mind online tools cant tell you whether or not you have a BRCA1/2 gene mutation or if you will get breast cancer. However, they may help you talk with your health care provider or a genetic counselor about these risks.

Coverage Of Breast Cancer Screening And Prevention Services

Among women in the United States, breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer death. In 2016, an estimated 3.5 million women in the U.S. were living with breast cancer. The Affordable Care Act and many state laws have provisions that assure that most women with private insurance, Medicaid, and Medicare have coverage for breast cancer screening services. This typically includes screening mammography for the general population of women, but also can include genetic testing and preventive medications for high-risk women over the age of 35. This factsheet discusses breast cancer screening and prevention services, and reviews the scope of private and public insurance coverage, as well as access to those services for women in the US.

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Does My Insurance Cover Brca Testing

If you have ovarian cancer, testing for a BRCA mutation may be covered in many cases. If you do not have cancer but are considered to be at a high risk for developing cancer, testing for a BRCA mutation should also be covered. Call your insurance provider or talk to your health care team to ask about any specific limitations.

Who Can Be Tested For Inherited Faulty Genes

The Breast Cancer Genetic Test And Your Insurance Policy

You may be eligible for an NHS genetic test if cancer runs in your family and you are worried you may get it too. The test can tell you whether you have inherited a faulty gene that increases your risk of cancer.

Testing for genes that increase the risk of cancer is called predictive genetic testing. A positive result means you have an increased risk of developing cancer. But it doesn’t mean that you have cancer or will definitely develop it.

You may be eligible for an NHS genetic test if:

  • an inherited faulty gene has already been found in one of your relatives or
  • there is a strong family history of cancer in your family

You need to be referred for genetic testing by a specialist doctor .

You can have private genetic testing. But you need to think about this carefully. You can find out more about private genetic testing at the bottom of this page.

At the genetic clinic, you see a genetic specialist or counsellor. They will:

  • look in detail at your family history
  • work out your risk of developing cancer
  • work out whether you need a genetic test

Your first appointment might be at the clinic or over the phone. During this meeting, the counsellor will ask you questions about any members of your family who have had cancer. And how old they were when diagnosed.

Your genetic clinic appointment is your chance to ask questions. If youre not sure what to ask you can look at our questions for your doctor.

You could print them out and add any other questions that you might have.

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Hysterectomy With Prophylactic Oophorectomy

The medical literature suggests that a prophylactic hysterectomy should be performed in conjunction with oophorectomy in women from families with Lynch syndrome I. However, for women from families with breast-ovarian cancer syndrome, site-specific ovarian cancer syndrome, or a family history of epithelial ovarian cancer who choose to have prophylactic oophorectomy, the choice to have prophylactic hysterectomy in conjunction with oophorectomy depends on the women’s attitudes regarding hormone replacement and the potential morbidity from the hysterectomy, either abdominally or vaginally.

An unilateral oophorectomy at the time of hysterectomy when both ovaries are in place is considered not medically necessary because this is considered inappropriate under current, generally accepted guidelines.

Emotional Risks For Family Members

Genetic testing may also have an emotional impact on family members.

Your genetic counselor may suggest you talk to your family about BRCA1/2 or expanded panel testing before you get tested or before you learn your results. That way you can find out if they want to know about your results.

For people with a BRCA1/2 or other high-risk inherited gene mutation, figuring out how to tell relatives can be hard.

Some family members may value the option of BRCA1/2 or panel testing. Others may be upset, anxious or angry about hearing the news.

If you have concerns about the best way to share the news with your family members, talk with a genetic counselor. You may prefer to write a letter to your relatives , especially if you have a big family. Your genetic counselor may be able to help you write this letter.

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Can I Do Genetic Testing At Home

Some at-home genetic tests can help you determine breast cancer risk. These tests typically involve providing a sample of saliva or cheek cells and sending the sample by mail to be tested.

Its recommended that you seek genetic testing from a healthcare professional rather than using an at-home test for the following reasons:

  • an incomplete result: At-home tests may not cover all known variants of a gene, such as BRCA1 or BRCA2. Because of this, a negative result can be misleading.
  • unnecessary alarm: At-home tests may detect common genetic variants that are only associated with a slight increase in breast cancer risk, meaning that a positive result may cause unnecessary alarm.
  • genetic counseling: With genetic testing through a healthcare professional, youll often also have access to genetic counseling both before and after you receive your result. This can help you better understand your result in the context of your overall health.
  • privacy: Your privacy may not be ensured when you use an at-home test. If you do choose to use one, carefully review a companys disclosure policy beforehand.

Getting genetic testing for breast cancer risk has several benefits. But there are some risks involved as well.

Annual Brca Testing Rates From 2009 To 2014

Does Medicare Cover Genetic Testing For Breast Cancer ...

From 2009 to 2014, BRCA testing rates per 100,000 women aged 1864 years enrolled in employer-sponsored health insurance increased 2.3 times in metropolitan areas and 3.0 times in nonmetropolitan areas . The relative difference in testing rates decreased by almost half from 36.9% in 2009 to 19.6% in 2014. BRCA testing rates were higher in metropolitan areas than in nonmetropolitan areas throughout the study period for women having any BRCA test and all BRCA test subtypes a . In 2014, the proportions of test subtypes were similar in metropolitan and nonmetropolitan areas, with 93.6% and 94.3% of women having full-gene sequencing tests, 87.3% and 87.5% of women having large rearrangement tests, and 4.4% and 4.6% of women having known mutation tests .

BRCA Testing Rates by Age Group

BRCA Testing Rates by Region

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What If I Dont Have A Strong Family History

After looking at your family history, the genetic doctor might tell you that its unlikely that you have an inherited faulty gene. In this case, your risk of cancer is the same as other members of the population.

In certain situations, the genetic counsellor might suggest you have regular screening. This is more likely if members of your family have breast or bowel cancer.

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How Genetic Testing Is Done

Genetic testing can be done on samples of blood or saliva, or from a swab of the inside of a cheek. The samples are sent to a lab for testing.

There are many different possible mutations in the BRCA genes. Testing can look for one specific mutation, or more extensive testing can be done to look for many different BRCA mutations. For example, if someone is being tested because they have a family member with a known BRCA mutation, testing might focus only on that specific mutation. In people of Ashkenazi Jewish descent, testing might focus on the specific BRCA mutations that are most common in this group of people. But if theres no reason to suspect a specific gene change, testing will likely look for many different BRCA mutations. Depending on the situation, testing might be done to look for changes in other genes as well.

Does Health Insurance Cover The Cost Of Genetic Testing For Brca1 And Brca2 Variants

Genetic Test For Breast Cancer: How Much Does It Cost?

People considering BRCA1 and BRCA2 variant testing may want to confirm their insurance coverage for genetic counseling and testing. Genetic counselors can often help answer questions about insurance coverage for genetic testing.

Some genetic testing companies may offer testing for inherited BRCA1 and BRCA2 variants at no charge to patients who lack insurance and meet specific financial and medical criteria.

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Genetic Counseling And Testing For Breast Cancer Risk

Some people inherit changes in certain genes that increase their risk of breast cancer . Genetic testing can look for mutations in some of these genes. While it can be helpful in some cases, not everyone needs to be tested, and each person should carefully consider the pros and cons of testing. Its very important to understand what genetic testing can and cant tell you before these tests are done.

Coverage For Breast Cancer Screening And Prevention

While several health organizations issue guidelines for breast cancer screening and prevention, private insurance coverage of preventive services under the ACA is governed by recommendations from the United States Preventive Services Task Force and the Health Resources and Services Administration . Under these guidelines, private group and individual insurance plans and state Medicaid expansion programs must cover the following breast cancer screening and prevention services at no cost to the consumer: 1) screening mammography at least every 2 years and as frequently as once a year for women ages 40 to 74 with average-risk for breast cancer 2) genetic counseling and testing for mutation of the BRCA1 and BRCA2 genes in some women with a personal or family history of breast, ovarian, fallopian tube, or peritoneal cancer 3) preventive medication for some women with elevated risk of breast cancer and at low risk for adverse medication effects . Some medical professionals recommend other services, such as screening MRIs for women at higher risk for breast cancer, but these services are not currently subject to the ACAâs preventive services coverage requirement.


Figure 3: Mammography Use in the United States by Age Group and Insurance Coverage

  • Mammography rates vary by state. Ohio and Kansas reported the highest mammography rates in the nation, while Connecticut reported the lowest rates at 61% .

Figure 4: Mammography Rates Vary Across States

Preventive Medication

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Variant Of Uncertain Significance

A VUS test result is not conclusive. However, most of the time, minor changes in a gene turn out to be normal variants. Most VUS results do not impact the genes ability to work, meaning they dont increase the risk of breast cancer. VUS results are usually treated similar to negative results.

VUS results are much more common with expanded panel testing than with BRCA1/2 genetic testing. Panel testing looks at many genes . With more genes in the test, its more likely youll get a VUS.

Over time, the lab may clarify the meaning of the VUS and send an updated test report to the health care provider who ordered the test. You should be notified if the VUS gets updated.

You can also check with the health care provider who ordered the test every 1-2 years to see if there is any new information about the VUS. While this may seem like a long time to wait, the information isnt likely to change very often.

A VUS test result can be confusing. If you have any questions about a VUS result, meet with a genetic counselor to go over the results.

Will I Be Covered If I Have To Leave Work Because Of Ovarian Cancer

Does Medicaid Cover Genetic Testing For Breast Cancer ...

If you are currently covered by insurance through your employer, the Family and Medical Leave Act provides up to 12 weeks of job-protected, unpaid leave during any 12-month period to eligible, covered employees to either care for their own serious health conditions or care for an immediate family member with a serious health condition. FMLA also requires that employees group health benefits be maintained during the leave.

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What To Do If You’re Worried

Speak to a GP if cancer runs in your family and you’re worried you may get it too. They may refer you to a local genetics service for an NHS genetic test, which will tell you if you have inherited one of the cancer risk genes.

This type of testing is known as predictive genetic testing. It’s “predictive” because a positive result means you have a greatly increased risk of developing cancer. It does not mean you have cancer or are definitely going to develop it.

You may be eligible for this NHS test if the faulty gene has already been identified in one of your relatives, or if there is a strong family history of cancer in your family.


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