Is Genetic Testing for Colon Cancer Covered by Insurance?

One of the best things about the implementation of the Affordable Care Act (ACA), or Obamacare, was the inclusion of provisions for preventive medicine. With coverage for many different types of regular health checkups, testing, and screening, Obamacare increased opportunities for early detection and preventive medical intervention, intended to reduce costs and ensure greater longevity and quality of life for patients.

These forms of preventive coverage included both general wellness exams (annual physicals, for example), and issues related to women’s and men’s health. For example, minimum coverage mandates included not only women’s health screenings (gynecological visits and mammograms), but also genetic testing for breast cancer.

Because of the increased risk of breast cancer for women carrying the BRAC1 or 2 gene mutations, this form of testing could allow for preventive care that saves lives, not to mention hundreds of thousands of dollars’ worth of treatment that could follow a cancer diagnosis. The tests themselves could number in the hundreds or thousands of dollars, preventing most women from paying for them out-of-pocket, but this pales in comparison to what insurance providers would have to pay for cancer treatments.

The same basic principle applies to genetic testing for colon cancer, but are insurance providers required to pay for this form of testing? Here’s what you need to know.

Colon Cancer Screenings
Following the implementation of the ACA, mandatory minimum requirements for insurance coverage included colorectal cancer screenings, such as colonoscopy. This testing can be used to catch early warning signs of colon cancer, as well as the early stages of cancer development.

Because early detection is crucial to fighting and surviving this and other forms of cancer, testing and screening options are generally deemed preventive care and therefore covered by insurance. However, not all forms of testing are considered essential.

Genetic Testing
In the case of genetic testing for certain conditions, including some forms of cancer, there may be some caveats to coverage. Although genetic testing is considered preventive since it allows patients the opportunity to make wise and informed decisions about their healthcare, it can be incredibly expensive and in some cases unnecessary.

For example, a family history of colon cancer puts patients at greater risk for developing cancer themselves, and in such cases, there would be a vested interest in determining whether genetic indicators of cancer exist, such as gene mutations. However, patients with no family history of certain cancers could be wasting money on such genetic tests, at least in the eyes of insurance providers.

While certain types of genetic testing are expressly included in ACA provision, such as genetic testing for breast cancer, others, like genetic testing for colon cancer, are subject to eligibility requirements for insurance coverage. What is required to become eligible for this coverage?

In most cases, health insurance plans will cover genetic testing for colon cancer in cases where it is deemed “medically necessary” and it is specifically recommended by your healthcare provider. It’s best to check with your insurance provider to find out the criteria for coverage, and you doctor and/or testing facilities can help you to make this determination.