Avalere Health
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Insights

Oct 08, 2013

More Variable Molecular Diagnostic Rates Likely

As molecular diagnostics become more common in treating certain diseases – especially cancer – their reimbursement will be an important part of value messaging for many drug therapies.

Updated Medicare payment rates for molecular pathology Current Procedural Terminology (CPT®) codes published by CMS on September 30, 2013 allow some manufacturers and labs a better sense of future payments, while others continue to guess how and if Medicare and other payers will reimburse for their tests. 

Only 65 of 114 codes originally priced in May were included in the September update. The Centers for Medicare & Medicaid Services (CMS) indicated that they only listed payment rates for tests currently paid by at least one Medicare Administrative Contractor (MAC), even though they published rates for the excluded 49 codes in May. As many commercial payers and Medicaid plans use Medicare payment rates as a base to determine their rates, manufacturers and labs may find difficulty in obtaining appropriate coverage and payment for many of the unpublished tests. 

In addition, some tests saw price increases from those published in May, while others saw decreases. For example, CPT code 81235, EGFR (epidermal growth factor receptor, common variants) saw a median national limitation amount (NLA) increase from $225 to $332.50. In contrast, CPT code 81275, KRAS, (v-Ki-ras2 Kirsten rat sarcoma viral oncogene), variants in codons 12 and 13, saw a median NLA decrease from $246.40 to $198.97. 

Reconsideration requests for 2014 rates are due to CMS by October 30, 2013. More information can be found on the CMS website.   

Avalere is the essential voice improving healthcare. We stay ahead of the curve and generate deep content for clients across the entire healthcare industry. We look forward to partnering with you to make better business decisions. For more information, please contact Caroline Pearson.
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