Medicare pays for genetic testing when the test is considered medically necessary and the criteria in applicable Local Coverage Determination policies are met. Medicare claims for services performed at Myriad Genetic Laboratories, Inc. are processed by the Medicare Administrative Contractor (MAC) for the state of Utah, Noridian Healthcare Solutions, LLC. Noridian has implemented the coverage policies and procedures of the MolDX program. For more information, see here.
Providers should consult Local Coverage Determination MolDX: BRCA1 and BRCA2 Genetic Testing* to determine if their patient meets criteria for genetic testing.
Providers should consult Local Coverage Determination MolDX: Lynch Syndrome Genetic Testing to determine if their patient meets criteria for genetic testing. Download the Supplementary Information Form to order COLARIS for your Medicare patients.
Healthcare providers can also obtain assistance in interpreting the criteria from Myriad’s Medical Services by calling Myriad at 800-469-7423, extension 3850.
For patients who do not meet Medicare criteria, an Advanced Beneficiary Notice of Non-coverage ( ABN for Personalized Medicine, ABN for Personalized Medicine en Español) is required before testing will begin. Because Medicare will likely not cover test costs for patients who do not meet Medicare criteria, test costs will be billed to the patient. A summary of instructions and documentation requirements for Medicare patients is included on page one of the ABN.
Medicare, Medicaid, or other federally funded programs will pay only for tests that meet their coverage criteria and are reasonable and necessary to treat or diagnose a patient. Medicare generally does not cover routine screening tests even if the physician or individuals authorized by law to order tests considers the tests appropriate for the patient. Laboratories are required to provide annual notice of these restrictions to physicians and other individuals ordering laboratory services. Here you will find an electronic copy of those notices.
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