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

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 coverage rules. The test must be medically necessary, ordered by a doctor, and performed by a lab that meets Medicare standards. Medicare does not cover genetic testing done for ancestry, genealogy, or general wellness screening — only tests tied to a health concern your doctor is investigating.

The coverage decision often comes down to two things: whether the test is on Medicare's list of covered services, and whether your doctor's reason for ordering it matches Medicare's medical necessity rules. Some genetic tests are covered in full; others are covered only under certain conditions; and some are not covered at all. Your out-of-pocket cost depends on which category your test falls into.

Key Takeaways

  • Medicare Part B covers genetic tests ordered by a doctor when they are medically necessary to diagnose or rule out a specific condition.
  • The test must be performed by a Medicare-approved lab, and your doctor must document the medical reason for ordering it.
  • Genetic tests for ancestry, genealogy, or general wellness are not covered by Medicare.
  • You pay 20 percent of the approved amount after you meet your Part B deductible, unless the lab is out-of-network.
  • Your doctor or the lab can contact Medicare before the test to find out whether it will be covered in your specific situation.

Which genetic tests Medicare covers

Medicare covers genetic tests that help diagnose inherited conditions, cancer risk, or other health problems your doctor is actively investigating. Common examples include tests for hereditary breast and ovarian cancer risk (BRCA1 and BRCA2 mutations), cystic fibrosis carrier status, sickle cell disease, and hereditary heart conditions. Tests for Alzheimer's disease risk, Parkinson's disease, and certain inherited metabolic disorders are also covered when ordered for the right reason.

The specific test must be on Medicare's list of covered laboratory services. Your doctor's office or the lab performing the test can check this list before you have the test done. If the test is not on the list, Medicare will not pay for it, even if your doctor thinks it is medically necessary. Some newer genetic tests are not yet on the list because Medicare has not reviewed them; others may never be covered.

Pharmacogenomic testing — which tells your doctor how your genes affect your response to certain medications — is covered in limited situations. Medicare covers it when you are already taking a medication and your doctor needs to know whether your genes affect how your body processes it. Medicare does not cover pharmacogenomic testing to predict how you might respond to a drug you have not yet taken.

What "medically necessary" means for genetic testing

Medicare requires your doctor to have a specific medical reason for ordering the test. You cannot straightforward ask for a genetic test because you are curious or worried about your family history. Your doctor must document that the test will help diagnose a condition you have symptoms of, rule out a condition you might have, or guide treatment decisions for a condition you already know you have.

For example, if you have a family history of hereditary breast cancer and your doctor suspects you may carry the BRCA mutation, Medicare will likely cover the test. If you have no symptoms and no personal or family history of the condition, but you want the test anyway, Medicare will not cover it. The difference is whether the test serves a diagnostic purpose tied to your current health situation.

Your doctor must also show that the test is the right tool for the job. If a simpler or less expensive test would answer the same question, Medicare may not cover the more expensive genetic test. Your doctor's documentation becomes important if Medicare questions whether the test was truly necessary.

How much you pay out of pocket

If Medicare covers your genetic test, you typically pay 20 percent of the approved amount after you meet your Part B deductible for the year. The approved amount is what Medicare decides the test is worth — not necessarily what the lab charges. If the lab is in-network with Medicare, they agree to accept Medicare's approved amount as payment in full (after your 20 percent). If the lab is out-of-network, you may owe more.

Your actual cost depends on whether you have already met your Part B deductible ($240 in 2024, though this amount changes each year). If you have not met it, you pay the full cost of the test until you reach the deductible, then pay 20 percent of the approved amount for any remaining balance. If you have a Medigap or Medicare Advantage plan, your out-of-pocket cost may be lower.

Some genetic tests are expensive — several hundred to several thousand dollars. Before you have the test, ask the lab for an estimate of what Medicare will approve and what you will owe. The lab can often tell you this by checking your Medicare coverage details.

How to learn about your test will be covered

The best time to check coverage is before you have the test done. Your doctor's office or the lab can contact Medicare to ask whether the test is covered in your situation. This is called a coverage information request, and it takes a few business days. Medicare will tell you yes, no, or "we need more information from your doctor."

You can also call Medicare directly at 1-800-MEDICARE (1-800-633-4227) and ask about a specific test. Have your Medicare number and your doctor's name ready. Medicare can tell you whether the test is on the covered list, but they may not be able to tell you whether it meets medical necessity rules for your specific situation without your doctor's input.

If Medicare says the test is not covered, you have options. You can pay for it yourself out of pocket. You can ask your doctor whether a different test might answer the same question and be covered by Medicare. Or you can ask Medicare to reconsider — your doctor can submit additional documentation explaining why the test is medically necessary in your case.

When Medicare denies coverage

Medicare may deny coverage if the test is not on the covered list, if your doctor's reason for ordering it does not meet medical necessity rules, or if the lab is not Medicare-approved. If you receive a denial notice, it will explain the reason. The notice will also tell you how to appeal — you have the right to ask Medicare to reconsider.

To appeal, you or your doctor can submit additional information explaining why the test was medically necessary. This might include your medical history, symptoms, family history, or other test results that support the need for genetic testing. The appeal process usually takes several weeks. If Medicare denies the appeal, you can request a hearing before an independent reviewer.

If you disagree with a denial and decide to have the test anyway and pay out of pocket, keep your receipt and documentation. You may be able to use the cost toward your medical expenses for tax purposes, depending on your situation.

Genetic testing through Medicare Advantage plans

If you have a Medicare Advantage plan (Part C) instead of Original Medicare, your coverage for genetic testing may be different. Medicare Advantage plans must cover at least what Original Medicare covers, but they can add extra coverage or have different rules about which labs you can use. Some plans cover genetic testing more broadly than Original Medicare does.

Check your plan's coverage documents or call your plan directly to ask about genetic testing. Your plan may require you to use an in-network lab or get prior approval from your doctor before the test. The cost-sharing rules (deductible, copay, or coinsurance) may also be different from Original Medicare.

Frequently Asked Questions

Does Medicare cover genetic testing for ancestry or genealogy?

No. Medicare only covers genetic testing ordered by a doctor for medical reasons — to diagnose, rule out, or guide treatment of a health condition. Tests done for ancestry, genealogy, or general curiosity are not covered, even if ordered by a doctor.

Will Medicare cover genetic testing if I have a family history of a disease but no symptoms?

It depends on the disease and your situation. If your family history puts you at high risk for a serious condition that your doctor thinks you should be tested for, Medicare may cover it. But if you have no symptoms and your doctor has no clinical reason to suspect you carry a genetic mutation, Medicare likely will not cover the test.

Can I get a genetic test through my Medicare Advantage plan if Original Medicare would not cover it?

Possibly. Medicare Advantage plans must cover what Original Medicare covers, but they can offer additional coverage. Call your plan to ask whether they cover the specific test your doctor ordered. Some plans have agreements with labs that Original Medicare does not use.

What if the lab says they will bill me directly instead of Medicare?

Ask the lab why. If the lab is not Medicare-approved, Medicare will not pay for the test no matter what, and you will owe the full cost. If the lab is Medicare-approved but is billing you directly, ask them to submit the claim to Medicare instead. If they refuse, contact Medicare to report it.

How long does it take to learn about Medicare will cover my genetic test?

A coverage information request usually takes three to five business days. If Medicare needs more information from your doctor, it may take longer. It is worth waiting for this answer before you have the test, because it tells you exactly what you will owe.