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Medicare pays for the CA 125 blood test to follow ovarian and related cancers after diagnosis, to check for recurrence and response to treatment, but not to diagnose a pelvic mass or to investigate symptoms.
United States, Medicare laboratory National Coverage Determination 190.28, version 2, effective 1 January 2006. The NCD describes CA 125 as "elevated in 80% of patients who present with epithelial ovarian carcinoma" and also in carcinomas of the fallopian tube, endometrium and endocervix, malignant mesothelioma and primary peritoneal carcinoma. Covered uses include a baseline before surgery for a suspicious pelvic mass, three levels in the first month after treatment to estimate the CA 125 half-life, a level at the end of chemotherapy, surveillance (the NCD states measurements "are generally obtained every 3 months for 2 years, every 6 months for the next 3 years, and yearly thereafter") and levels before each cycle in advanced or recurrent disease.
Limitations: not covered "for the evaluation of patients with signs or symptoms suggestive of malignancy", and "specifically not covered for aiding in the differential diagnosis of patients with a pelvic mass as the sensitivity and specificity of the test is not sufficient". CMS publishes quarterly lists of covered diagnosis codes for it; the latest listed is October 2026.
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