CMS: Medicare Will Cover Genetic Diagnostics For Certain Cancers

Medicare will now cover Next Generation Sequencing for beneficiaries with inherited ovarian or breast cancer in order to improve their precision medicine treatment options, CMS announced.

“Innovative technologies are transforming medicine, and at every turn, President Trump has shown a dogged determination to give Americans access to them,” said CMS Administrator Seema Verma “We recognize that cancer patients shoulder a heavy burden, so we’re leaving no stone unturned in supporting women’s health and getting all patients the care they need. NGS testing provides clinically valuable information to guide patients and physicians in developing a personalized treatment plan.”

Next Generation Sequencing is a test that analyzes a patient’s genetic makeup in order to pursue precision medicine. By investigating the inherited cancer at such a close level, the patient and his or her provider can determine the best treatment path. Next Generation Sequencing may help identify beneficiaries who can participate in clinical trials.

CMS acknowledged the lack of options for beneficiaries with inherited cancers. The press release cited these treatment restrictions as a primary motivator for the agency’s decision to cover Next Generation Sequencing.

In addition to Next Generation Sequencing, CMS expanded Medicare’s Administrative Contractors’ flexibility in covering other indications. The agency explained that this decision will allow beneficiaries to access new, innovative diagnostics faster.

Precision medicine and early diagnoses have been linked to better patient outcomes and lower healthcare spending. As a result, private health payers have joined CMS in pursuing precision medicine and investigating genetic diagnostics for earlier diagnosis. These tools are especially employed for cancer diagnosis and treatment.

Aetna developed its own precision medicine program through BRCA gene testing for breast and ovarian cancers. The major payer not only established its own BRCA gene testing program but also set a genetic information privacy policy and was the first payer to implement quality credentialing for its genetic testing labs.

“As our understanding of genomics continues to grow, we are seeing the development of a new generation of genetic testing and targeted treatments,” said Joanne Armstrong, MD, MPH, senior medical director at Aetna, in the announcement. “Although we have a long way to go to replace the current ‘one size fits all’ medical model with individualized genetics diagnostics and hyper-specific treatments, the evolution of this field is exciting.”

Cancers are not the only diseases for which payers might turn to precision medicine.

Blue Cross Blue Shield Association has shared data on multiple sclerosis in the hopes that it will assist payers in formatting stronger precision medicine approaches for the disease.

“The future of medicine for patients with conditions like MS lies in precision medicine, or tailoring treatment based on genetic makeup, environment and behavior,” Vincent Nelson, MD, vice president of medical affairs in the Office of Clinical Affairs at Blue Cross Blue Shield Association, told HealthPayerIntelligence.com.

CMS shares Armstrong and Nelson’s optimism.

“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,” the press release stated.