Thursday, September 30, 2021

Very Brief Blog; NGS MAC Releases New Draft Policy for Solid Tumors (DL37810)

See an update with link to a public meeting here.


The NGS MAC, which manages New York/New England as well as MN/WI/IL, has proposed a new LCD for "genomic sequence panels in the treatment of solid neoplasms."  It's policy DL37810 and under comment September 30-November 13.

Find the LCD here: 

The LCD  provides GSP coverage for advanced lung cancer and advanced colon cancer patients.  I find the policy a little confusing, since it seems to cover both codes 81445 (5-50 genes) and 81455 (51+genes) in the billing article.  But it predicates "medical necessity" on only 4-5 precisely named genes in each cancer (lung and colon) so it's unclear to me from the text when the patient's medical necessity (under the wording of the text) would require 51+ genes.  To be continued.


The NGS MAC is interesting from a genomics perspective.   They pay for a lot of national genomics services, but only under 2 codes, codes which are controlled by national NCDs (Foundation Medicine in Massachusetts and Exact Sciences Cologuard in Wisconsin).   Except for those two nationally controlled and very highly utilized molecular codes, billing for the rest of the whole range of molecular tests (e.g. codes 81162 to 81599) are far less utilized in NGS MAC states than the other states.  This doesn't mean NGS MAC patients get any less molecular testing, since genomic tests are often processed across state lines and they are billed where the lab is.  In addition, possibly more labs in these regions are hospital-based and don't show up in routine CMS Part B claims data.