The interface of Medicare coverage decision-making and emerging molecular-based laboratory testing

Burken, Mitchell I.; Wilson, Kathleen; Heller, Karen; Pratt, Victoria M.; Schoonmaker, Michele; Seifter, Eli

doi:10.1097/gim.0b013e3181976829

Cited by 9 publications

(9 citation statements)

References 11 publications

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“…17 In 2006, a California Medicare Administrative Contractor published a local coverage determination for reimbursement of the test for women with early-stage ER + , node-negative breast cancers. 18 A recent retrospective analysis of the Surveillance, Epidemiology, and End Results (SEER) registry of Medicarelinked data for 70,802 beneficiaries revealed an increase in utilization of the test from 1.1% in 2005 to 10.1% in 2009 among Medicare beneficiaries. 19 Other utilization studies were limited to small groups of several hundred patients.…”

Section: Original Research Articlementioning

confidence: 99%

Implementation of the 21-gene recurrence score test in the United States in 2011

Lynch

Berse

Petkov

et al. 2016

Genetics in Medicine

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Section: Original Research Articlementioning

confidence: 99%

Implementation of the 21-gene recurrence score test in the United States in 2011

Lynch

Berse

Petkov

et al. 2016

Genetics in Medicine

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“…Previous researchers have discussed coverage policy development and have even discussed policy formulation and considerations for genetic testing specifically. 10-15 Although researchers have described policy development processes, few studies have examined the coverage policies themselves. Recently, Latchaw et al reviewed policies of ten private payers in Illinois and observed wide variability in coverage.…”

Section: Introductionmentioning

confidence: 99%

Eligibility criteria in private and public coverage policies for BRCA genetic testing and genetic counseling

Wang

Beattie

Ponce

et al. 2011

Genetics in Medicine

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Purpose Coverage policies for genetic services for hereditary cancers are of interest because the services influence cancer risk reduction for both persons with cancer as well as their family members. We compared coverage policies for BRCA genetic testing and genetic counseling among selected payers in the US to illuminate eligibility criteria variation that may explain differential access by insurance type. We compared these policies to policies for breast cancer screening with MRI to consider whether payers apply a unique policy approach to genetic services. Methods We conducted a case study of large private and public payers selected on number of covered lives. We examined coverage policies for BRCA genetic testing, genetic counseling, and screening with MRI and the eligibility criteria for each. We compared eligibility criteria against National Comprehensive Cancer Network guidelines. Results Eligibility criteria for BRCA testing were related to personal history and family history of cancer. Although private payers covered BRCA testing for persons with and without cancer, the local Medicare carrier in our study only covered testing for persons with cancer. In contrast, Arizona's Medicaid program did not cover BRCA testing at all. Few payers had detailed eligibility criteria for genetic counseling. Private payers have more detailed coverage policies for both genetic services and screening with MRI in comparison to public payers. Conclusion Despite clinical guidelines establishing standards for BRCA testing, we found differences in coverage policies particularly between private and public payers. Future research and policy discussions can consider how differences in private and public payer policies influence access to genetic technologies and health outcomes.

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“…There are two formal processes Medicare uses to develop and disseminate coverage decisions and criteria for utilization of medical services: NCDs and LCDs. 4 The main outcome of either process is to define the clinical scenario and parameters for a medical service, which are paired with appropriate ICD-10 codes and CPT codes, to establish the coverage criteria. NCDs and LCDs define the clinical scenario necessary for coverage, as well as limited or noncoverage, of specific clinical procedures.…”

Section: Coveragementioning

confidence: 99%

Molecular Pathology Economics 101: An Overview of Molecular Diagnostics Coding, Coverage, and Reimbursement

Sireci

Patel

Joseph

et al. 2020

The Journal of Molecular Diagnostics

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Widespread indications for use of molecular diagnostics in various aspects of clinical medicine have driven proliferation of testing. The rapid adoption and continuous technological evolution of molecular diagnostics have often strained the development and maintenance of a functional underlying framework of coding, coverage, and reimbursement policies, thereby presenting challenges to various stakeholders, including molecular professionals, payers, and patients. A multidisciplinary working group convened by the Association for Molecular Pathology Economic Affairs Committee was tasked to describe the complex landscape of molecular pathology economics and highlight opportunities for member engagement. In this article, on the basis of review and synthesis of government Supported exclusively by the Association for Molecular Pathology.

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The interface of Medicare coverage decision-making and emerging molecular-based laboratory testing

Cited by 9 publications

References 11 publications

Implementation of the 21-gene recurrence score test in the United States in 2011

Implementation of the 21-gene recurrence score test in the United States in 2011

Eligibility criteria in private and public coverage policies for BRCA genetic testing and genetic counseling

Molecular Pathology Economics 101: An Overview of Molecular Diagnostics Coding, Coverage, and Reimbursement

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