Medicare covers some genetic tests, but not all — it depends on the type of test and why your doctor ordered it

Medicare Part B covers genetic testing when your doctor orders it to diagnose or rule out a specific genetic condition you have symptoms of, or to guide treatment decisions for a condition you already have. The test must be medically necessary, not done for screening purposes alone or for ancestry information. Your doctor's order and medical records are what Medicare reviews — not the test name or the lab that runs it.

The most common covered tests are for hereditary cancers (like BRCA1 and BRCA2 mutations), familial heart conditions, and genetic causes of dementia or movement disorders. Medicare also covers some pharmacogenetic tests, which show how your genes affect which medications will work best for you. Carrier screening — testing to see if you carry a gene for a condition you don't have — is usually not covered unless you have a family history of a specific genetic disorder and your doctor documents medical necessity.

Key Takeaways

  • Medicare Part B covers genetic testing ordered by your doctor when it is medically necessary to diagnose a condition or guide treatment, but not for screening or ancestry purposes.
  • Your doctor must document in your medical record why the test is needed and what condition it is meant to diagnose or treat.
  • You typically pay 20 percent of the Medicare-approved amount after you meet your Part B deductible, though some labs may charge more than Medicare allows.
  • Genetic counseling before or after testing is covered by Medicare when ordered by your doctor, and many insurers cover it even when the genetic test itself is not.
  • If Medicare denies the test, you have the right to appeal, and your doctor can request a coverage information before you have the test done.

How Medicare decides what genetic tests to cover

Medicare uses a process called a Local Coverage information (LCD) to decide which genetic tests it will pay for in your area. Each of the 12 Medicare Administrative Contractors (MACs) that process claims in different regions may have slightly different rules, so a test covered in one state might not be covered in another. Your doctor's office or the genetic testing lab can check with your MAC to see whether a specific test is covered before you have it done.

The main thing Medicare looks for is whether the test will change your treatment or diagnosis. If your doctor is ordering a test because you have symptoms that could be caused by a genetic condition, or because you have a family history of a genetic disorder and your doctor thinks you might have it, Medicare is more likely to cover it. If the test is being done purely for information — to see if you carry a gene for something that hasn't shown up in your family, or to learn about your ancestry — Medicare will not pay for it.

Your doctor must write an order that explains why the test is medically necessary. The lab will send this order to Medicare along with your test results. If Medicare thinks the test was not medically necessary, it may deny the claim. You can appeal a denial, and your doctor can also request what is called a "coverage information" before you have the test, which gives you a written answer about whether Medicare will pay.

What you will pay out of pocket

If Medicare covers your genetic test, you pay 20 percent of the Medicare-approved amount after you meet your Part B deductible for the year. The deductible is set each year by Medicare — in 2024 it is $240, but this amount changes annually. Once you have paid that deductible, you owe 20 percent of what Medicare allows for the test itself.

The complication is that not all labs charge the same amount, and not all labs accept Medicare's approved amount as payment in full. Some labs are "in-network" with Medicare and agree to accept what Medicare pays plus your 20 percent coinsurance. Others may bill you for the difference between what they charge and what Medicare allows. Before you have the test, ask the lab whether they accept Medicare assignment — this means they will not bill you for more than Medicare allows.

If the lab does not accept Medicare assignment and charges more than the Medicare-approved amount, you could owe significantly more. This is why it is worth asking your doctor which lab they plan to use and confirming with that lab that they accept Medicare assignment.

Genetic counseling and what it covers

Genetic counseling — a session with a genetic counselor who explains what a test can and cannot tell you, discusses your family history, and helps you understand results — is covered by Medicare when your doctor orders it. You pay the same 20 percent coinsurance after your deductible. Many people find counseling helpful before a test, to understand what the results might mean, and after a test, to understand what to do with the information.

Some insurance plans and health systems cover genetic counseling even when they do not cover the genetic test itself, so it is worth asking your doctor or insurance plan whether counseling is available to you. Genetic counselors are specially trained in both genetics and how to discuss complex medical information, and they can answer questions your doctor may not have time for.

Tests Medicare usually does not cover

Medicare does not cover carrier screening unless you have a documented family history of a specific genetic condition. Carrier screening tells you whether you carry one copy of a gene for a recessive condition — meaning you would not get the disease, but your children could if the other parent also carries the gene. This is often done before pregnancy, but Medicare considers it preventive rather than medically necessary unless there is a clear family history.

Ancestry testing and direct-to-consumer genetic tests are never covered by Medicare, even if ordered by a doctor. Whole genome sequencing — testing your entire genetic code — is covered only in very specific circumstances, usually when a diagnosis has not been found after other testing. Expanded carrier panels that test for dozens of conditions at once are usually not covered unless your doctor can document that you have a family history of one of those specific conditions.

Pharmacogenetic testing — which shows how your genes affect medication response — is increasingly covered, but coverage varies by MAC and by which medications are involved. Ask your doctor or the lab whether your specific pharmacogenetic test is covered before you have it done.

What to do if Medicare denies your genetic test

If Medicare denies your claim for a genetic test, you have the right to appeal. The first step is usually a redetermination, where you or your doctor can ask Medicare to look at the claim again and explain why the test was medically necessary. Your doctor's written explanation of why the test was needed can be very important here.

If the redetermination is denied, you can ask for a reconsideration by an independent reviewer. This process takes longer but gives you another chance to present your case. Your doctor can help by writing a letter explaining the medical reason for the test and how it changed your care.

Before you have a test done, you can also ask your doctor to request a coverage information from Medicare. This is a formal question to Medicare asking whether they will cover a specific test for your specific situation. It takes a few weeks but gives you a written answer before you have the test, so you know what to expect.

Questions to ask your doctor before genetic testing

Ask your doctor whether the test is covered by Medicare and whether they have checked with your MAC. Ask which lab they plan to use and whether that lab accepts Medicare assignment. Ask what the test can and cannot tell you, what happens if the results are abnormal, and whether genetic counseling is available. Ask whether your doctor can request a coverage information from Medicare before you have the test, so you know in advance whether Medicare will pay.

If your doctor is recommending a test that Medicare might not cover, ask whether there are other tests that Medicare does cover that could give you similar information. Ask what the out-of-pocket cost would be if Medicare does not cover it, and whether the lab offers a payment plan.

Frequently Asked Questions

Does Medicare cover BRCA testing?

Yes, Medicare covers BRCA1 and BRCA2 testing when your doctor orders it because you have a personal or family history of breast, ovarian, or related cancers. You must have symptoms or a family history that makes the test medically necessary — Medicare does not cover BRCA testing for screening alone in people with no symptoms or family history.

Will Medicare cover genetic testing if I have no symptoms?

Medicare covers genetic testing without symptoms only if you have a strong family history of a specific genetic condition and your doctor documents that the test is medically necessary. Screening tests for people with no symptoms or family history are not covered.

What if my genetic test costs more than Medicare allows?

If the lab accepts Medicare assignment, they cannot bill you for more than Medicare allows plus your 20 percent coinsurance. If they do not accept assignment, ask before the test whether they will bill you for the difference. Some labs offer discounts or payment plans for out-of-pocket costs.

Can I get a genetic test through Medicare Advantage instead of Original Medicare?

Medicare Advantage plans must cover the same genetic tests that Original Medicare covers, but they may have different rules about which labs you can use or whether you need prior authorization. Contact your plan to ask whether a specific test is covered before you have it done.

Does Medicare cover genetic testing for Alzheimer's disease risk?

Medicare covers genetic testing for hereditary forms of Alzheimer's disease when you have symptoms or a family history of early-onset dementia. Testing for the APOE4 gene, which increases risk but does not cause Alzheimer's, is usually not covered because it is considered predictive rather than diagnostic.