If the woman has an Ashkenazi history, the LCD requires her to first have founder mutation testing (CPT code 81212, $440) and then if it is negative, to proceed to regular BRCA sequencing (81211+81213, $2948.84).
Financially this doesn't make sense, and in terms of screening efficiency it obviously doesn't make sense.
The rate of being BRCA-positive in Ashkenazi women with breast cancer has a base rate of 25%. It is higher (30%) in women < 45, and lower (18%) in women > 45. Medicare populations are almost entirely > 65, so the rate would be below 18% in a Medicare population.
Running these numbers for FCSO's LCD at current Medicare rates, at the overall population rate of 25% positive, screening testing followed 81211/13 testing would cost $265,163. Running the numbers with the lower 18% rate for the over-45 population, testing would cost $285,805. However, if FCSO simply directed patients immediately to BRCA comprehensive sequencing (code 81162), total costs would be $225,293.
In short, the screen-first policy wastes BOTH money AND time. Thanks, Medicare.
It's not in the short term interest of a Florida lab to poin tthis out and request a revision, as the lab gets more money under the policy. (The policy is financially break even for Medicare only if the BRCA-positive rate is higher than 40%.)
|click to enlarge|
The LCD requires 81212 testing in all patients then reflex to 81211+81213. If it reflexed to 81162, it would still lose money in the >45 population, and waste just as much time.