Header: CMS still stores publicly available cloud data on lab test pricing surveyed in 2017 and representing CY2016.
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Congress and CMS are re-activating the PAMA reporting process. For reporting laboratories who had >$12500 in Medicare payments in 1H 2025, they will report data on all claims paid by commercial payors in 1H2025, and they will report in May-June-July 2025. See websites and announcements at CMS.
https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule/clfs-reporting
The prior survey reporting 1H2016, reported and posted in 2017. This set a new fee schedule for 2018 forward.
See the 2016/2017 Cloud Data
At the time, CMS published a gigantic cloud database of reported prices. I thought that was no longer available, but it seems it is. The data can be pretty interesting.
On this page:
https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs
see "CLFS Applicable Raw Data File from 2017 Reporting."
That sends you here:
For example, if you search 81211 (a popular BRCA code in 2016), you get 374 rows of data.
I wasn't sure how that squares with a contemporary old 2017 data file I havea for PAMA 81211, which has 2364 rows of pricing data for 81211. From 2364 (my file) to 374 (online file today), about 85% of the rows are msising. This is because the current cloud data leaves out all price reporting with less than 10 units per line, and my old file with 2364 lines includes many lines with only 1 or 2 payments at that price. The overall shape of the data would be the same, just scaled down.
For example, the 2016 data I have (with 2364 rows) for BRCA 81211 shows a large price peak around $2900, which I assume reflect Myriad payments (this was not long after the BRCA Supreme Court case), and relatively few commercial payments at the CMS rate back then (around $2200) but another peak of payments around $1800, which was 85% of the CLFS at the time. So I inferred (this is just armchair guessing) that Myriad was cruising along with numerous legacy contracts in the $3000 range for BRCA 81211, while new entrants were entering the newly opened BRCA market often at 85% of the CLFS.
It was also notable that the thin tail of cheapest payments went below $100 and thin thin top end had the rare payment over $6000.
81455
AMA CPT created code 81445 (5-50 tumor genes) and 81455 (51+ tumor genes) at the same time. 81445 was gapfill priced to about $600, but 81455 was not priced by MACs. However, in 2016 PAMA claims reported in 2017, the (current) database shows 53 claims. (Recall it excludes any line with 9 or less units).
For 81455, there were 14 claims at $9,900, 11 claims at $1,600, 18 claims at $3579, and 10 claims at $4500. From this, you'd expect the median was $3579, but it was actually $2916 when all claims (including those prices used 9 times or less) were counted. We learned from BRCA claims for 81211 that the exclusion of price levels with 9 or less paid claims omitted over 80% of the total data.
