Medicaid Coverage of NCCN- and ASCO/SSO-Guideline-Concordant BRCA Germline Testing for Patients with Breast Cancer: Opportunity to Embrace Rapid Advancements in Precision Medicine

Recent advancements in therapeutics for BRCA-associated breast cancer have changed indications for germline genetic testing. This study investigated whether Medicaid plans cover National Comprehensive Cancer Network (NCCN)-concordant and/or American Society for Clinical Oncology/Society for Surgical Oncology (ASCO/SSO)-concordant BRCA germline testing for patients with breast cancer.

Publicly available, complete, and original state Medicaid plans for all 50 states were reviewed to determine coverage criteria for BRCA genetic testing for patients with breast cancer and clinical cancer geneticist consultation. States were categorized into discrete categories on the basis of the policy language.

Only 58% (n = 29) of state Medicaid plans explicitly or implicitly cover NCCN-concordant BRCA testing. Of the remaining 21 states, 85% reference out-of-date NCCN criteria, suggesting delayed uptake of new guidelines. Only one state (Colorado) covers ASCO/SSO guideline-concordant BRCA testing for newly diagnosed breast cancer. Nearly all state Medicaid plans (98%, n = 49) cover clinical cancer genetics consultation.

Significant variation in Medicaid coverage for BRCA germline mutation testing may inadvertently exclude socially and economically marginalized populations from the emerging standard of care. Policy language should consider explicit mention of coverage in accordance with NCCN guidelines.