Diagnostic Value and Access Flashcards
What part of Medicare covers biomarker testing for NSCLC patients?
Medicare Part B or Medicare Advantage, under the medical benefit.
Name three factors impacting the coverage of biomarker tests.
Number of genes; single-gene tests have broader and more favorable insurance coverage than multi-gene panels
Sample type; tissue-based tests have broader coverage than liquid biomarker testing
Regulatory status; FDA approval is not required for biomarker tests to be covered by payers
___% of NSCLC patients are covered by Medicare for biomarker tests
73%
A Local Coverage Determination (LCD) (can / cannot) supersede any part of a National Coverage Determination (NCD)
Cannot
True or False; the National Coverage Determination (NCD) only covers FDA-approved NGS panels and prohibits repeated testing with the same NGS test.
True
True or False; Local Coverage Determination (LCD) applies to some biomarker tests other than FDA-approved NGS panels
False; all biomarker tests
Who is responsible for creating Local Coverage Determination (LCDs)?
Hint: 7 total in the US with 4 total biomarker test coverage policies
Medicare Administrative Contractors (MACs)
Name five services provided by Laboratory Benefit Managers (LBMs)
Prior authorization administration
Medical policy development
Claims process and management
Lab network maintenance
Physician decision support
Average patient Out of Pocket (OOP) is $__ under Medicare and $__ under commercial insurance.
$0 and $65
__ of top 5 commercial payers now cover at least one NGS test
4
For Medicare beneficiaries that are managed by MoIDx MACs, biomarker tests must be billed with the proper ___ or ___ code and a ___ code.
CPT Category 1, PLA, Z-code
Which type of code is unique to each biomarker test?
CPT Category 1
CPT PLA
CPT PLA
What type of code is used by labs and manufacturers who want to more specifically identify their test?
CPT Category 1
CPT PLA
CPT Category 1
