CMS approves Medicare coverage of next-generation sequencing tests for inherited ovarian, breast cancers

Medicare can now cover breakthrough laboratory diagnostic tests that use next-generation sequencing for patients with inherited ovarian or breast cancer.

The decision, announced Monday by the Centers for Medicare & Medicaid Services (CMS), is the latest move by the agency to address how to cover costly new cancer diagnostics and treatments. CMS decided to first cover lab diagnostic tests using next-gen sequencing in March 2018 for patients with certain advanced cancers.

“As a result of today’s decision, more Medicare patients will have access to NGS in managing other types of inherited cancers to reduce mortality and improve health outcomes,” CMS said in a release Monday.

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The agency added that Medicare patients with inherited cancers have “few treatment options available.” The expansion of testing creates new opportunities for patients to get more personalized care, CMS added.

“Patients who use [next-gen sequencing] tests may also find they are good candidates for cancer clinical trials,” the agency said.

CMS added that it is providing Medicare Administrative Contractors, which are private insurers that process Medicare claims, with discretion on whether to cover next-gen sequencing tests for other types of cancers and indications.

The agency has made moves over the past several years to cover the emergence of pricier cancer treatments and diagnostics.

In August 2019, CMS gave a national coverage determination to extend Medicare coverage for immunotherapy drugs that comprise CAR T-cell therapy. The treatments have cost patients up to $1 million after factoring in hospital administration costs.

Starting in 2020, CMS also increased the new technology add-on payment from 50% to 65%. CMS can decide to provide an additional payment to a hospital for new technologies that can significantly improve clinical outcomes.