Very Brief Blog: CMS Releases First Transmittal on NCD for Cancer Tumor Testing

In March 2018, CMS released its ground-breaking National Coverage Determination for next generation sequencing tests used in oncology. 

CMS has released its first official "transmittal to contractors" (MACs) on how they should implement the NCD.   This transmittal primarily replicates the effective coverage text of the NCD, and includes a long list of oncology codes that support payment under the NCD.   (The ICD-10 codes must be associated with patient qualifications, such as having advanced/metastatic cancer.)

• Download the November 30 transmittal here. 
• The PDF was very slightly updated after its initial release to clarify that one long set of ICD10 codes in the back (all solid tumor oncology codes) are for FMI CDx, and a one page set of lung codes is for Thermo Oncomine 0022U.
• Since the NCD does almost nothing except cut/paste/replicate the NCD text, along with the full cut/paste of the ICD-10 oncology code list, it's unclear why it took eight months to be issued.

Workload and task instructions in the transmittal at 10878.4, 10878.5, request MACs to work collaboratively to ensure consistent editing and attend "up to 4 one hour calls" to discuss implementation of the NCD and to provide consensus recommendations on implementation in a "final report to CMS" (10878.5).

What This Is Not

This is not detailed claims processing instructions.  CMS states those will be released in the first as amendments to the CMS "Claims Processing Manual."   CMS says point blank in the introductory paragraph that "A subsequent CR will be released at a later date" with more claims processing instructions.

The NCD has a number of implications that are subject to interpretation, or on which experts disagree.  My best guess is that the Claims Processing Manual rules, when they come out, will generally quote from the existing NCD and may not resolve alot of the remaining fuzzy issues.

What It Says Re LCDs

Regarding coverage by LCDs, the transmittal says that:

Medicare Administrative Contractors may determine coverage of other diagnostic laboratory tests using NGS for patients with cancer only - 

when the test is performed in a CLIA-certified laboratory, ordered by the treating physician and the patient has: 
• either recurrent, relapsed, refractory, metastatic, or advanced stages III or IV cancer; and,• either not been previously tested using the same NGS test for the same primary diagnosis of cancer or repeat testing using the same NGS test only when a new primary cancer diagnosis is made by the treating physician; and,• decided to seek further cancer treatment (e.g. therapeutic chemotherapy).
A diagnostic laboratory test using NGS is non-covered when cancer patients do not have the above-noted indications for cancer. 

MACs have covered NGS tests in women with breast cancer & and high family history, and Lynch testing in colorectal cancer, including when the cancer is not metastatic, so MACs will have to decide how to apply the above text in those situations.  (To not cover BRCA panel or Lynch panel in non metastatic patients can't possibly be an intention of the NCD authors, though, since they reviewed only CDx issues in cancer patients and didn't even touch the literature on BRCA panels or Lynch testing, so the effect of the NCD shouldn't pertain to those areas.) 

There are also puzzles such as a new first presentation of advanced leukemia, which isn't literally "recurrent" or "metastatic" or not known to be "refractory" since it hasn't had first-therapy yet, the words found in the bullet-points of the NCD.  But is surely "advanced cancer," the heading of the NCD as a whole.

The NCD covers gene panel testing in some situations that might seem surprising, such as if you have a very small, but recurrent, squamous skin cancer of the trunk (code C44.509).

CMS classifies some high-cost NCDs as payable by Part A/B rather than Medicare Advantage.  I haven't seen a statement that CMS has classified this NCD that way.

My Short Deck on LCD/NCD and Combination Diagnostics: For NextGenDx Conference in DC

This week is the 1000-person NextGenerationDx conference in Washington, here.

This afternoon I have the chance to present a concise 15-minute PowerPoint deck on changing CMS policy for combination diagnostics - both the LCD and NCD levels.    

The presentation is in the cloud as a PDF here.

White Paper: Three Rubik's Cube Puzzles of the CMS NGS NCD

• Below is my April 2018 article on some odd twists and turns in the CMS NCD.
• For my January 2, 2019 article on how bizarre the interpretation of the NCD has become, see here.
• For my January 22, 2019 article, after coverage at Genomeweb, here.
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Original April 2018 Article and Cloud PDF White Paper

We're celebrating one month after the publication of the final NCD from Medicare on the use of NGS testing in advanced cancer patients.   I've written up a 10-page white paper on three puzzles of the NCD.    Find the white paper online HERE.   Click the "Down" arrow to download.

Based on incoming questions that I hear, andbased on some of my own puzzling, here are the three topics.  The short version is this blog; the long version is the online white paper.

     1.  Why does FMI assert pan cancer coverage under the NCD?
     2.  How does the NCD text limit the scope of the NCD?
     3.  Possible implications of the "advanced cancer" definition in the NCD.

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1.  Why does FMI assert pan cancer coverage under the NCD?

The NCD provides coverage for tests that are NGS based, FDA-authorized CDx tests, when used in a patient who has an indication for that test.   FMI has two indications.  One indication for use as a CDx in several genes and several cancers (such as EGFR, lung, CDx).   A second indication is for "tumor profiling to inform the physician in solid cancers."   If a Medicare patient has lung cancer, the CDx for EGFR checks both boxes: the test is a CDx test, and, has an indication (EGFR) in that patient.   If a Medicare patient has bladder cancer, or skin cancer, or thyroid cancer, the test is still a CDx test (box 1) and it has "an indication" for that patient, e.g. tumor profiling to aid the physician in a solid cancer.   This analysis concords with FMI statements in several press releases.

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Getting a pan cancer definition isn't easy; FMI provided 80,000 blocks across 43 cancers, and MSK IMPACT provided >10,000 blocks across 17 cancers.

2.  How does the NCD text limit the scope of the NCD?

The proposed NCD had clear cut exclusionary language, which CMS simply deleted from the final version.  In addition, CMS deliberately added several additional sentences for the public, regarding the "scope" of the NCD:

click to enlarge

This language seems initially clear, then a little murky (to exactly what do some terms refer?) on closer reading.  I provide an analysis under Section 2 of this white paper. 

As I've said earlier, trying to read the NCD (including the text above) as broader and more exclusionary collides with common sense and lands in arbitrary and capricious.  For example, applying the NCD to unrelated NGS topics other than cancer therapy would be just like doing an NCD on cardiac devices, limiting the scope to valves, and then concluding that pacemakers aren't covered by implication.


3.  Possible Implications of the CMS "Advanced Cancer" Definition

The title of the NCD is "NGS testing in advanced cancers" and CMS provides coverage for targeted therapy NGS testing only in advanced cancers.  CMS seems to take pains to provide an explicit operational definition of "advanced cancers:" cancers that are recurrent, relapsed, refractory, metastatic, or Stage III or Stage IV. 

Is the NCD Language too restrictive?  For example, a new aggressive leukemia isn't relapsed or recurrent - it's new - and it's not refractory, because we're going to treat it for the first time.  Leukemia isn't usually called "metastatic" or "stage III or IV."  (There are staging systems for leukemia but they're unrelated to the metastatic Stage III/IV in solid tumors).   Could some auditor assert the leukemia doesn't meet any single one of the entrance criteria?

Can the LCD language in some cases too generous?  There's no question that skin cancer is a cancer, and millions of them are "recurrent."  When they recur, patients will certainly want "a therapy" (be it excision, radiation, topical drug, etc).   So here we go: The patient has a "cancer' and it is "recurrent' and he needs "a therapy" (not otherwise specified by NCD), so the skin cancer seems to qualify.  And if he has several (left hand, right hand, forehead) each is a distinct primary eligible for testing.   I'm not recommending this, I'm just reading the NCD.