Medicare Administrative Contractors Update Genetic Testing Coverage for Oncology

Medicare Administrative Contractors (MACs) Novitas and FCSO released finalized local coverage determinations (LCDs) for genetic tests for oncology: L39365 and L39367, respectively.

The change comes after the College of American Pathologists (CAP) and 44 other health care organizations cosigned a letter in September 2023 to express their concern with the MACs’ proposed framework, which would outsource review to three third-party compendia to govern coverage policy.

Additionally, in its own letter, CAP recommended that Novitas and FCSO remove all references to third-party compendia from final LCDs, allow for additional genetic testing for hereditary cancer syndromes, and add Current Procedural Terminology codes 81503, 81538, and 81540 to ensure uniform coverage for tests continues following the final Genetic Testing for Oncology LCD.

The finalized LCDs include the following changes:

• Coverage for genetic tests that are excluded from three knowledgebases -- National Comprehensive Cancer Network guidelines, OncoKb, and ClinGen -- will no longer be delegated. The knowledgebases will continue to be used as evidence resources.
• Genetic tests for hereditary cancer syndromes included in the LCD will not be limited to once per patient’s lifecycle, leaving the decision to retest a patient up to the patient’s provider.
• The list of diagnostic billing codes has been expanded.

The changes are scheduled to take effect on April 24, 2025.

Link to the September 26, 2023 article for previous information.

Sources:

https://www.cap.org/advocacy/latest-news-and-practice-data/february-4-2025#story5

https://www.cap.org/advocacy/latest-news-and-practice-data/september-19-2023#story3