Genetic Testing for Hereditary Breast, Ovarian, Pancreatic and Prostate Cancer - Medicare Advantage (Revised)

By August 3, 2026: Billing and clinical teams must implement the updated genetic testing coverage policy for Medicare Advantage beneficiaries. (1) Billing team: Update prior authorization templates and claims submission systems to reflect new coverage criteria for multigene panel testing (hereditary breast, ovarian, pancreatic, prostate cancer), known familial variant testing, Li-Fraumeni syndrome, and PTEN hamartoma tumor syndrome/Cowden syndrome testing. (2) Provider/ordering physicians: Ensure test orders include appropriate medical necessity documentation per policy requirements before submission. (3) Prior authorization staff: Familiarize with jurisdiction-specific MACs and their applicable LCDs (J5, J8, J6, JK, J15, JE, JF, JH, JL, JJ, JM, JN) as coverage varies by geographic location. (4) Claims processing: Route claims through jurisdiction-specific MACs using their designated LCDs (e.g., MolDX LDT criteria for inherited cancer syndromes). For jurisdictions without CMS guidance (J6/JK, JH/JL, JN), apply LCD L38972 criteria. Failure to align with updated policy will result in claim denials and rework.