Thursday, February 1, 2018

NGS MAC Proposes LCD: PLA Codes and Admin_MAAA Codes Not Covered

On February 1, 2018, the NGS MAC (several midwestern states, New York, and New England) issued a draft LCD for public comment that states all administrative MAAA codes (00XXM) and PLA codes (00XXU) are non covered until an explicit coverage decision is made.  LCD DL37600 is online here.

This would mean the MAC does not need to do claim-by-claim review for each instance of each MAAA or PLA code as they come in.   Rather, they could be denied up front until a future date when a coverage decision was made.   The policy wouldn't apply to Category I MAAA codes (815XX).

The comment date runs through April 11, 2018.   The policy echoes a master MolDx LCD, used in all 28 states where MolDx is effective, that non-covers a wide range of molecular CPT codes until such time as a coverage article or policy is written for each CPT code in the non-covered range (here).

The proposal may be one new step in an ongoing tug-of-war between efforts to move regulatory processes faster (including accelerated approval at FDA, here, and rapidly issued codes, here) and the amount of evidence required before coverage decisions by payers.

Another consultant pointed out there is a small silver lining.  If a test has no LCD, and the manufacturer requests an LCD, there is actually no official path for that.  The MAC doesn't have to provide a meaningful response or make an LCD.   They can all but "circular file" a request for a new LCD.  But, here, a new PLA test would formally request a "reconsideration" of the PLA LCD, and the MAC would have to log it, process it, and respond formally under a set of rules and a fixed timeline.