H.R. 4752 — Reducing Hereditary Cancer Act

This section establishes Medicare Part B coverage for germline mutation testing (i.e., hereditary cancer genetic testing) for individuals with a personal or family history of a hereditary cancer gene mutation or a personal or family history suspicious for hereditary cancer, as a covered medical and other health service under section 1861(s)(2)(KK) of the Social Security Act. It defines such testing in new section 1861(nnn) as genetic testing for germline mutations in accordance with evidence-based clinical practice guidelines from nationally recognized oncology professional organizations (e.g., National Comprehensive Cancer Network, American Society of Clinical Oncology), using the least restrictive guideline in cases of conflict as determined by a Medicare administrative contractor. The section further excludes from coverage any such testing performed more than once for an individual, under section 1862(a)(1)(Q). The amendments apply to testing furnished on or after the date of enactment.

This section establishes Medicare coverage under parts A and B for risk-reducing surgeries—based on evidence-based clinical practice guidelines (as defined in SSA §1861(lll))—for individuals described in SSA §1861(s)(2)(II) (i.e., women at high risk for breast or ovarian cancer eligible for BRCA1/BRCA2 genetic counseling and testing), by deeming such surgeries reasonable and necessary under the statutory exclusion in SSA §1862(a)(1)(A). (As background, Medicare previously did not cover preventive risk-reducing surgeries such as prophylactic mastectomy or oophorectomy, as they address future rather than existing illness.) The provision applies to items and services furnished on or after the date of enactment.

This section directs the Secretary to increase Medicare frequency limitations on coverage of evidence-based cancer screenings (e.g., screening mammography, breast screening MRI, colonoscopy, PSA testing, and other modalities recommended by clinical practice guidelines for high-risk individuals) for beneficiaries determined by genetic testing to have a hereditary cancer (germline) gene mutation, to at least an annual basis or as specified in such guidelines (section 1861(lll) of the Social Security Act). It makes a conforming amendment to the screening mammography payment provision (42 U.S.C. 1395m(c)(2)(A)) and applies to items and services furnished on or after enactment.