Foundation Medicine's National Coverage Determination Reopened by CMS
In a session held during the Florida Society of Clinical Oncology’s annual meeting in April, panelist James Almas, MD, vice president and national medical director of clinical effectiveness at LabCorp, and previously a medical officer at CMS in the Coverage Analysis Group, announced that he expected the National Coverage Determination to be reopened for Foundation Medicine’s FDA-approved companion diagnostic. By the end of the month, CMS revealed that they had done just that.
In a session held during the Florida Society of Clinical Oncology’s annual meeting in April, panelist James Almas, MD, vice president and national medical director of clinical effectiveness at LabCorp, and previously a medical officer at CMS in the Coverage Analysis Group, announced that he expected the National Coverage Determination (NCD) to be reopened at any time for Foundation Medicine’s FDA-approved broad companion diagnostic for solid tumors. By the end of the month, CMS revealed that they had done just that.
“The NCD that was ultimately issued has flaws in it. The NCD does not allow for the same test to be used more than once, with 1 exception,…”
While the
At the start this year, the NCD was at odds with some local coverage determinations (LCDs) in terms of NGS testing allowed for BRCA1/2 mutations. The NCD for Foundation Medicine only allows testing of these patients with late-stage disease, while Medicare contractor Palmetto GBA allowed for the testing in early-stage patients. Palmetto was
However, based on the language in the original NCD, stakeholders believed the policy was restricted to when NGS testing was used for tumor-profiling tests for patients with recurrent, relapsed, refractory, metastatic, or advanced stage III or IV disease.
This policy caused confusion amongst laboratories, as it was viewed as removing coverage for germline NGS testing for early-stage patients, a type of test commonly performed to detect germline mutations in BRCA1/2 to gauge patients’ risk of breast and ovarian cancer.
In February, 63 healthcare companies and organizations, including the American Medical Association, the American Clinical Laboratory Association, and more,
CMS accepted public comments through May 29. A proposed decision memo is due October 29, and the new NCD is expected to be finalized by January 27, 2020.
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