Wednesday, September 28, 2022

The Quirky World of CMS Pharmacogenetics Pricing (Fall 2022 Price Proposals)

Update.  Final pricing in late November yielded no changes except 81418, Six Gene Panel, is going to be gapfilled rather than crosswalked to $742.  


On Friday evening, September 23, 2022, CMS released some 100 new codes and proposed prices for CY2022, and accepts public comment for 30 days.

See my original blog here.

AMA Six-Gene Panel

I took time to sort out the PGx codes, of which there are 7.  As I've ordered them in the cloud spreadsheet here, the first code is the AMA's own proposal for PGX of 6 or more genes, which CMS proposes to price at $742.

Myriad GeneSight

The next is the Myriad GENESIGHT test, with 15 genes, for psychiatry, which CMS proposes to price at $1336.   (The current MolDx price is $1568.64, although it used to be higher at  $2183.)

After that, the next four codes are variations of PGX panels from OneOme, and frankly, the pricing doesn't make sense to me, so maybe there's something over my head here.   Here we go.

OneOme #1

Of the four One Ome codes, I've ordered smaller to larger, with the first being the 16 gene panel.  CMS proposes to price at $1336, the same as the 15 gene Myriad panel just mentioned.  OK.

OneOme #2

The next is the OneOme 25 gene panel, and CMS drops the proposed price from $1336 to $742.  Hmm?

OneOme #3,#4

The final two OneOme codes are 0X45U/0343U, and 0X52U/0350U.   Both are 27 gene panels with identical text for the most part.   One lacks the phrase "gene drug interactions" and CMS proposes $1336.  

The other one has identical language but adds the phrase "gene drug interactions" and CMS drops the price to $742.   This is a little head-spinning for me.  I don't know if there's a typo or if there's something going on that is escaping me.

3 gene panel, RPRD

The final PGX code is a small 3 gene panel from RPRD labs in Wisconsin, CMS proposes $134, the price of a small warfarin panel 0030U.   

I've put a cloud spreadsheet at this link.

It's not too readable but I'm including a JPEG also:

click to enlarge

And a line chart: