8. A comparative analysis of reimbursement for molecular pathology testing for neoplasia

Abstract

Chromosome microarray Testing (CMA) and targeted mutation panel Next Generation Sequencing (NGS) are incorporated in the Pathways testing algorithms for hematologic disorders used at our institution. The objective of this project is to understand the reimbursement landscape for these two tests when applied to hematologic neoplasia. We examined the global reimbursement data from consecutive patients tested in fiscal year 2017 and performed detailed analysis on samples with service dates between July 2016 and February 2017. Overall, 56% of the samples billed for CMA with CPT code 81406 were reimbursed while 79% billed for NGS with 81450 and 81455 was reimbursed. Of all patients billed, 43% was covered by commercial health insurers and 50% by Medicare or Medicaid. Commercial insurers reimbursed a higher percentage of CMA tests while Medicare reimbursed a higher percentage of NGS tests. Of 184 CMA tests in the detailed subset analysis, 54% with normal results and 51% with abnormal results were reimbursed; Of 154 NGS tests, 83% with normal results and 81% with abnormal results were reimbursed. The most common reasons for denial was lack of appropriate pre-authorization and lack of any coverage. In conclusion, the current reimbursement for CMA and NGS tests are low but encouraging. There is no evidence of bias in coverage for abnormal versus normal results. Our data suggest that the reimbursement will improve with more acceptance of clinical utility of these tests in cancer, more robust pre-authorization mechanisms, and a well-established MediCare fee schedule. These findings set the stage for future surveys across institutions.