Does Medicare Cover Genetic Testing? Who Qualifies

Does Medicare cover genetic testing? If your doctor just mentioned a test, it does when the test is a medically necessary diagnostic lab test your provider orders. For gene sequencing, the national rule is NCD 90.2, which reaches only people with cancer and comes with a checklist to clear. A cancer diagnosis and a testing decision at the same time is a lot, so here is how the coverage works and what to ask.

In This Guide

• Key Takeaways
• Does Medicare Cover Genetic Testing? The Short Answer
• Does Medicare Cover Genetic Testing for Cancer? What Qualifies
• Where Medicare Coverage Stops
• What a Covered Genetic Test Costs
• How to Get a Genetic Test Covered
• If Medicare Denies the Test or You Get a Bill
• Frequently Asked Questions
• Learn More

Does Medicare Cover Genetic Testing? The Short Answer

Medicare covers genetic testing when it's a medically necessary diagnostic laboratory test your health care provider orders, meaning your doctor is using it to figure out or manage a condition you already have. Medicare also covers some preventive tests and screenings.1 Which of those descriptions your test fits decides the answer.

The clearest example is cancer. Medicare covers a category of genetic test called Next-Generation Sequencing for certain cancer patients, and we'll walk through exactly who qualifies below. What that national coverage doesn't reach is a panel no treating physician ordered, or a test for someone with no cancer diagnosis behind it.

Does Medicare Cover Genetic Testing for Cancer? What Qualifies

The main pathway is a national rule called National Coverage Determination (NCD) 90.2, which the Centers for Medicare & Medicaid Services uses to cover Next-Generation Sequencing (NGS), a type of genetic test that reads large stretches of DNA at once. Under Part B, Medicare covers NGS as a diagnostic laboratory test for people with cancer when a treating physician orders it and the test runs in a CLIA-certified lab. The NCD applies only to diagnostic lab tests using NGS for somatic (acquired) and germline (inherited) cancer.1

There are two situations here, and they work a little differently. Here they are side by side:

The details behind each column:

Somatic testing reads the DNA of the tumor itself, the mutations a cancer picked up along the way. Medicare covers it nationally for services on or after March 16, 2018. You need all of these:

• Recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer.
• No earlier test with the same NGS test for the same cancer genetic content.
• A decision to seek further cancer treatment.
• A test with FDA approval or clearance as a companion in vitro diagnostic for your cancer.

Miss any of those and the test isn't covered nationally, though your regional contractor may still cover some of those cases (more on that below).1

A typical case: say a parent with stage IV cancer has an oncologist who orders tumor sequencing. If the test is FDA-approved as a companion diagnostic for that cancer, runs in a CLIA-certified lab, and the other conditions are met, it is covered nationally and you usually pay nothing for the test itself. If it misses a condition, such as the FDA companion requirement, national coverage doesn't apply, but the MAC may still cover it, so the office should ask before the test is run.1

Germline testing reads inherited DNA, the genes you were born with, to see whether a cancer runs in the family. Medicare added national coverage for germline NGS as a diagnostic test effective January 27, 2020, but only for patients with ovarian or breast cancer who have a clinical indication for germline testing for hereditary breast or ovarian cancer and a risk factor for it, who haven't already had the same germline NGS test for the same genetic content, and when the test has FDA approval or clearance.1

The common thread: both are diagnostic tests for someone who already has cancer, ordered by the doctor treating it.

Where Medicare Coverage Stops

Medicare's national coverage for gene sequencing is narrow on purpose. NCD 90.2 applies only to diagnostic lab tests using NGS for somatic and germline cancer, and it says outright that NGS for a patient with acquired cancer is nationally non-covered when the criteria above aren't met.1 So these sit outside it. If you paid for a test that falls in this list, it can sting, and the next steps are below.

• A test no treating physician ordered, including a direct-to-consumer DNA kit you buy on your own.
• A test for someone with no cancer diagnosis behind it.
• A repeat of the same NGS test, for the same genetic content, you've already been tested with.

One category is left to the regional level rather than settled nationally: NGS used for RNA sequencing and protein analysis is for your Medicare Administrative Contractor (MAC), the company that processes claims in your region, to decide.1

Failing the national criteria isn't always the end of the road. The same NCD lets your MAC decide on coverage in two situations national coverage doesn't reach:1

• Tumor testing: your contractor can say yes for the same advanced cancers, with the same conditions (CLIA-certified lab, treating physician's order, no prior identical test, a decision to seek further treatment), even when the test isn't an FDA companion diagnostic.
• Inherited testing: your contractor can say yes for any cancer diagnosis, not only ovarian or breast. It needs a clinical indication, a risk factor for hereditary cancer, no prior identical test, and results sent to the treating physician.

That's the contractor's call, not a guarantee, but it's worth asking about before you assume the answer is no.1 Questions about your coverage can go to 1-800-MEDICARE (1-800-633-4227).3

Underneath all of it sits the general rule for lab work. According to Medicare.gov, Part B covers medically necessary diagnostic laboratory tests when your health care provider orders them, and Medicare also covers some preventive tests and screenings.1

If you've had a genetic test done and paid out of pocket, the order behind it is the first place to look: Part B's laboratory coverage runs through a test your health care provider ordered because it was medically necessary.1 If the order was there and Medicare still said no, see the section on denials below.

What a Covered Genetic Test Costs

So what does a covered genetic test actually run you? When the test qualifies as a diagnostic laboratory test your doctor orders, the general Part B lab-test rule applies: you usually pay nothing for a Medicare-covered diagnostic lab test.1 If the same visit also involves other services, an office visit or a specialist consult, those follow standard Part B rules: you pay the annual deductible ($283 in 2026) and then 20% of the Medicare-approved amount.2

If you have a Medicare Advantage plan instead of Original Medicare, the plan must cover the medically necessary Part A and B services Original Medicare covers, but most plans use networks, and a plan may require prior authorization (plan approval) before covering certain services.4 So before the test is run, ask the plan two things: is the lab in your network, and does the test need prior authorization?

How to Get a Genetic Test Covered

Every covered genetic test above runs through the same door: a treating physician has to order it, and it has to be medically necessary for your diagnosis.1 It comes from the doctor treating you, not from a test you arrange on your own.

A few practical steps:

1. Talk to the doctor treating the condition, usually an oncologist for cancer NGS testing.
2. Ask them to confirm the test meets Medicare's coverage rules for your specific situation before it's ordered.
3. Check that the lab is CLIA-certified, since NCD 90.2 requires the test be performed in a CLIA-certified laboratory.1

Questions worth asking the office before anything gets run:

• Is this ordered as Next-Generation Sequencing under NCD 90.2?
• Is the test FDA-approved or cleared as a companion diagnostic for my cancer?
• Is the lab CLIA-certified, and does it bill Medicare?
• If Medicare may not cover it, will I be asked to sign a notice first?

If you still have a coverage question, 1-800-MEDICARE is open 24 hours a day, 7 days a week.3

If Medicare Denies the Test or You Get a Bill

Before a test Medicare usually covers but expects to deny, an Original Medicare provider may give you a written notice called an Advance Beneficiary Notice of Noncoverage (ABN). It is not an official Medicare denial. If you choose the option to have the provider bill Medicare and Medicare denies the claim, you are responsible for payment but can appeal. If you choose to have the test without Medicare being billed, you can't appeal.5

If Medicare denies a claim, you can appeal. For Original Medicare the first step is a redetermination by your MAC, requested within 120 days of receiving the initial determination on your Medicare Summary Notice.6 A Medicare Advantage plan has its own process, which starts with the plan and must be filed within 65 days of the date on the plan's denial notice.6 Medicare's ABN notice rules apply only to Original Medicare.5

Learn More

Find personalized help understanding whether a parent's genetic test will be covered at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.