CMS Considers Genetic Testing Coverage

The Medicare Evidence Development and Coverage Advisory Committee (MedCAC) came together May 6 to discuss whether genetic testing improves health outcomes enough to warrant Medicare coverage. Does screening genetic testing change the natural history and/or reduce the complications of the disease and alter morbidity/mortality? The Centers for Medicare & Medicaid Services (CMS) wants to know.

The Secretary’s Advisory Committee on Genetics, Health and Society (SACGHS) defines genetic testing as “… any test performed using molecular biology methods to test DNA or RNA, including germline, heritable, and acquired somatic variations.”

Note the difference: In contrast to diagnostic tests, screening tests are administered to asymptomatic individuals for the prevention or early detection of illness or disability.

Screening services currently covered my Medicare include: mammography, glaucoma, pelvic exam and Pap test, diabetes, lipids, colorectal cancer, and prostate cancer. There is no national coverage decision (NCD) for screening genetic tests.

CMS asked MedCAC to address a series of questions at the meeting. A score sheet for questions requiring a vote is available on the CMS Web site.

In short, the panel indicated a fairly high confidence level that screening improves survival and other patient-focused health care outcomes. The panel also expressed fairly high confidence that quality-adjusted life years would be gained and that a decrease in incidence of illness or disability or net gain in other patient-focused health care outcomes would be realized. The panel was dubious, however, as to whether any net changes in lifetime costs of illnesses or disability would occur.

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3 Responses to “CMS Considers Genetic Testing Coverage”

  1. Elizabeth says:

    Forwarding in case you think the counselors might be interested.

  2. Belinda Frausto says:

    This is great news for genetic counseling. Currently, genetic counseling is not covered by medicaid unless and MD see’s the patient. We have a non boarded genetic counselor that will see the patient and bill code 96040. I would like to know if they did cover the testing would they begin covering the genetic counseling visit by a non boarded counselor. WV doesnt have licensed genetic counselors but they can be board certified. Our maternal fetal medicine providers feel this is necessary and we are currently writing off the charge because its not covered.

    Thanks Belinda

  3. Kathy Baker says:

    Has anyone billed these service by the physician (not counselor) – if so, did you use the preventative medicine codes vs new E&M codes due to the patient not have a sign or symptom? Did you use the V-codes as 1st listed? Personal or Family History are not accepted as first listed nor V82.71. How about V71.89?
    Thanks for your input!
    Kathy

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