Medicare covers some genetic tests, but not all — and the rules depend on why your doctor ordered the test and what gene it checks.

Medicare Part B pays for genetic testing when your doctor orders it to diagnose or rule out a specific medical condition, and when the test meets Medicare's medical necessity standard. That means the test has to be reasonable and necessary for your care — not done for curiosity, ancestry, or general screening without symptoms or risk factors.

The catch: Medicare does not cover all genetic tests equally. Some tests are covered under specific circumstances. Others are not covered at all. Your doctor's documentation of why the test is medically necessary makes the difference between Medicare paying and you paying out of pocket.

Key Takeaways

  • Medicare Part B covers genetic tests ordered by your doctor when the test is medically necessary to diagnose or rule out a condition you have symptoms of or a documented family history for.
  • Tests for hereditary cancers like BRCA1 and BRCA2 are covered when you meet specific criteria — usually a personal history of cancer or a close relative who had cancer before age 50.
  • Pharmacogenomic testing (which checks how your genes affect medication response) is covered for certain drugs, but your doctor must document medical necessity.
  • Ancestry tests, wellness screening, and genetic tests done without a medical reason are never covered by Medicare.
  • Your doctor should verify coverage before the test is done, because some labs bill differently and you may owe money if the test is deemed not medically necessary.

Which genetic tests Medicare usually covers

Medicare covers genetic testing for hereditary cancer syndromes when you have a personal history of cancer or a documented family history that puts you at risk. The most common covered tests are for BRCA1 and BRCA2 mutations, which increase the risk of breast, ovarian, and other cancers. If you have been diagnosed with breast or ovarian cancer, or if a close blood relative (parent, sibling, or child) was diagnosed with these cancers before age 50, your doctor can order BRCA testing and Medicare will typically pay.

Medicare also covers genetic testing for Lynch syndrome (hereditary nonpolyposis colorectal cancer, or HNPCC) when you have a personal history of colorectal cancer or a family member with colorectal cancer diagnosed before age 50. Testing for other hereditary cancer syndromes — like familial adenomatous polyposis (FAP) and hereditary diffuse gastric cancer (HDGC) — is covered under similar criteria.

Pharmacogenomic testing is covered when your doctor orders it to determine how your genes affect your response to a specific medication. For example, if you are starting warfarin (a blood thinner) or certain psychiatric medications, genetic testing can help your doctor choose the right dose. Medicare covers this test only when your doctor documents that the test will change your treatment plan.

Genetic testing for cystic fibrosis, sickle cell disease, and other inherited disorders is covered when ordered by your doctor for diagnostic purposes — usually when you have symptoms or a family history that suggests the condition.

Tests Medicare does not cover

Medicare does not cover genetic testing for ancestry or genealogy purposes, even if a medical provider orders it. Tests that show your ethnic background or family tree connections are considered personal interest, not medical care.

Genetic screening without symptoms or documented risk factors is not covered. If you have no personal history of cancer and no family history of hereditary cancer, Medicare will not pay for BRCA testing just because you want to know your status. The same applies to other genetic tests — Medicare requires a medical reason tied to your health situation.

Whole-genome sequencing and broad genetic panels are covered only in specific circumstances and only when your doctor can document that the broader test is medically necessary. A fishing expedition through your entire genome is not covered.

How to know if your test will be covered

Before your genetic test is done, ask your doctor to check with Medicare or your lab about coverage. Many labs have genetic counselors or billing staff who can tell you whether Medicare will pay based on your diagnosis and medical history. This step takes a few days but can save you hundreds or thousands of dollars.

Your doctor should document in your medical record why the test is medically necessary — your symptoms, your personal cancer history, or your family history. This documentation is what Medicare reviewers look at if there is a question about coverage later. If your doctor is unsure whether the test meets Medicare's standard, ask them to submit the case to Medicare for a coverage information before the test is done. This is called a coverage information request or prior authorization, depending on your plan.

If you have a Medicare Advantage plan (Part C) instead of Original Medicare, your plan may have different rules about genetic testing. Call your plan directly to ask what genetic tests are covered and whether you need prior authorization.

What happens if Medicare denies the test

If Medicare denies payment for a genetic test, you have the right to appeal. Your doctor or the lab can file an appeal on your behalf, usually within 120 days of the denial. The appeal should include documentation of your medical history and why the test was medically necessary.

If you paid for the test out of pocket before Medicare denied it, you can still file an appeal and ask for reimbursement. Keep all receipts and billing statements. If the appeal is successful, Medicare will pay you back.

If the appeal is denied and you believe the decision was wrong, you can request an independent review through Medicare's appeals process. This is a longer process, but it gives you another chance to present your case.

Out-of-pocket costs if Medicare pays

If Medicare covers your genetic test, you will owe your Part B deductible (if you have not met it yet) and 20 percent coinsurance after the deductible. The deductible amount changes each year. In 2024, the Part B deductible was $240, but this amount varies year to year.

The actual cost of a genetic test varies widely depending on the test type and the lab. A single-gene test might cost $500 to $2,000. A multi-gene panel can cost $2,000 to $5,000 or more. If Medicare covers the test, the lab will bill Medicare first, and you will owe only your share. If Medicare does not cover it, you may owe the full amount unless you negotiated a lower price with the lab beforehand.

Genetic counseling and Medicare

Many people benefit from talking to a genetic counselor before or after genetic testing. A genetic counselor can explain what the test does, what the results mean, and what your options are. Medicare covers genetic counseling when it is ordered by your doctor and is related to a covered genetic test or a condition with a genetic component.

Genetic counseling is usually covered as part of your doctor's visit or as a separate service billed under a specific code. Ask your doctor whether genetic counseling is covered in your situation, and whether you need to see the counselor in person or whether a telehealth visit is an option.

Frequently Asked Questions

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

Medicare does not routinely cover genetic testing for Alzheimer's risk in people without symptoms. However, if you are enrolled in a Medicare-covered clinical trial studying Alzheimer's genetics, the test may be covered as part of the trial. Talk to your doctor about whether a clinical trial is an option for you.

Will Medicare pay for genetic testing if my doctor thinks I might have a hereditary condition but I have no symptoms?

It depends on the condition and your family history. If you have a documented family history of a hereditary condition — for example, a parent or sibling with Lynch syndrome — Medicare may cover testing even if you have no symptoms yet. Your doctor needs to document the family history in your medical record. If you have no symptoms and no family history, coverage is unlikely.

What if I had genetic testing done before I turned 65 and now I am on Medicare — will Medicare pay for it retroactively?

No. Medicare covers services only after you are enrolled in Medicare. Tests done before you turned 65 or before your Medicare coverage started are your responsibility, even if you would have been covered if you had waited.

Can I use my Medicare Advantage plan instead of Original Medicare to get genetic testing covered?

Yes, but the rules may be different. Medicare Advantage plans must cover at least what Original Medicare covers, but they can have different requirements — like prior authorization or using a specific lab. Call your plan to ask what genetic tests are covered and what steps you need to take before the test.

Does Medicare cover genetic testing for my children or grandchildren?

No. Medicare covers only services for people enrolled in Medicare. If your children or grandchildren need genetic testing, they would need to use their own insurance or pay out of pocket. However, your genetic test results can help your doctor recommend testing for your relatives, and their doctors can use your results to support a medical necessity case with their insurance.