Wednesday, May 10, 2017

Brief Blog: BCBS-Mass - An Unusually Broad Cancer Gene Panel Testing Policy

A colleague today pointed me to BCBS Massachusetts online medical policy (#790) for tumor gene panels - online here.  If I'm reading the title correctly, it's a broad policy for most members in HMO/PPO plans, as well as Medicare Advantage HMO and Medicare Advantage PPO.

The policy cites underlying New England Medicare LCDs for gene panel coverage in lung cancer and in AML.  However - and this caught me by surprise - it seems to go much further in its coverage of additional solid cancers and additional hematopoetic cancers than do the Medicare LCDs it cites.

The BCBS policy is worth a close look.  It has a brief prologue of text before it presents several gene tables and diagnosis panels.  Later (after pages of ICD-10 listings) there are several pages of additional text analysis and discussion (don't miss pp. 16-18).
Allowable solid cancers for gene panel testing include: bladder, breast, cholangiocarcinoma, colorectal, endometrial, GI stromal, glioma, medulloblastoma, melanoma, meningioma, neuroblastoma, NSCLC, rare tumors with < 5000 incidence, stomach, esophageal, thyroid, and unknown primary.  B cell and T Cell NHL appear in both the solid tumor and hematopoetic tables.  Other blood conditions include AML, B-ALL, T-ALL, plasma cell dyscrasia, myelodysplasia, Myeloproliferative disorder.

Side Notes

Regarding the "surprise value" of the policy, for comparison, Aetna appears to cover gene panels (5-50 genes) only in lung cancer, among solid tumors.  Most CMS MACs also cover gene panels in lung cancer, but to my knowledge, only MolDX states are expanding to colon, melanoma, and breast this year.

Coding is directed to 81445, '50, '55.  The policy appears to date mostly from 7/2016.
Nerd Note.
On page 2, there is a section that boggles me:

"The use of panels containing fewer genes than listed in tables 1A or 1B may be medically necessary if all the genes in the smaller panel are listed in Table 1A or 1B."   Huh?