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PreventionGenetics Laboratory Stewardship - Insurance Advocacy at it’s Best

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At PreventionGenetics we try to go above and beyond to help patients get the insurance coverage they deserve.  We recently discovered an important issue with our Medicare Local Coverage Determination (LCD) L35000 that governs genetic testing for WI, MN and IL.  Claims for BRCA1/2 testing (CPT Code 81162) submitted to the contractor that covers this 3 state region would be denied unless the patient was assigned one of two specific breast cancer ICD-10 codes.

“We performed BRCA1/2 testing for a patient suffering from ovarian cancer, and filed a claim to Medicare using the ICD-10 code for ovarian cancer.   When we learned the claim was denied, I was eager to sort out what was happening”, said Michelle Apsey, Insurance specialist.  “I reached out to our Director of Genetic Counseling, Christina Zaleski, who pulled current National Cancer Coalition Network (NCCN) guidelines and compared these to the L35000 policy. This comparison led us to realize that the claim was denied because this patient did not have a diagnosis of breast cancer.”  We went on to compare our area’s LCD with the LCDs for genetic testing of other Medicare areas, and came to realize that L35000 was very restrictive in comparison.  The L35000  policy would only cover BRCA1/2 testing if the patient had that one cancer type. “Together we realized that our LCD policy did not align with current NCCN Guidelines, and limited access to this important testing. We decided that it was time to advocate for changing our LCD; we just weren’t sure how we were going to accomplish that,” Zaleski commented.

While Michelle worked on a third appeal for our patient with ovarian cancer, Christina reached out to genetic counseling colleagues in the region from Mayo Medical Labs and University of Chicago, to see if they had problems related to the LCD policy.  She also contacted colleagues in other regions with experience advocating for policy change and colleagues at PLUGS (Patient-Centered Lab Utilization Guidance Services) where PreventionGenetics is a gold sponsor.   After learning that PreventionGenetics might be the only laboratory in our area that regularly submits Medicare claims for Hereditary Breast and Ovarian Cancer, a decision was made that PreventionGenetics would advocate for change.  

Initially, Medicare agreed to add one additional ICD-10 code to cover ovarian cancer, but still not fully satisfied, we continued to challenge the decision.  Ultimately, after submitting a 6 page document citing literature and evidence, with 32 references, Medicare took us seriously and our reconsideration request was submitted to contracted medical directors for review.

We were recently notified that, effective Jan 1, 2018, the L35000 LCD has been updated with 74 additional ICD-10 codes.  If there is medical necessity and patients meet current NCCN guidelines, there are now approved ICD-10 codes for the following cancer types:

  • Ovarian
  • Fallopian tube
  • Peritoneum
  • Pancreatic
  • Male breast
  • Nipple & areola
  • Prostate

The process took a few months, but tenacity paid off.  Ultimately, many more patients with Medicare are eligible for BRCA1/2 testing.  “We raised our voice to advocate for Medicare policy change.  We were able to submit peer reviewed publications and merit for our request and our appeal was heard.  Through open communication with Medicare, we were able to influence a major change to the policy and ultimately secure a win for patients with Medicare,” concluded Zaleski.