Medicare Now Covers Next-Generation Genomic Sequencing Tests

06.01.2020 | Jason Gillespie

The Centers for Medicare & Medicaid Services (CMS) has announced that Medicare will now cover Next-Generation Genomic Sequencing for cancer patients. This step makes the latest diagnostic techniques available for the 100 million people covered by CMS.

What is Next Generation Sequencing?

Next Generation Sequencing (NGS) is a new diagnostic technique. It makes it possible to sequence variations in RNA and DNA very quickly so that diagnosticians can spot genetic mutations linked to cancer.

When NGS is combined with other diagnostic methods, it provides a complete picture of the patient’s diagnosis. So, their diagnosis and treatment can be personalized for their genetic profile.

How does NGS coverage help patients?

In practice, that personalized treatment could mean access to specific cancer drugs, or being selected for new treatment trials. As cancer treatments become more sophisticated, researchers are looking for patients with highly specific genetic profiles.

The decision by CMS also extends coverage to a wider range of cancer patients. NGS will now be available for Medicare patients with recurrent, relapsed, refractory, metastatic cancer, or advanced stage III or IV cancer. Patients will also have access to repeat testing if they receive a new primary cancer diagnosis.

What does this mean for healthcare providers and Medicare billing?

The CMS decision was a National Coverage Determination, meaning that it applies to Medicare patients throughout the US. The Determination covers in vitro diagnostic tests which are approved by the FDA. However, Local Medicare Administrative Contractors have the power to decide whether they will reimburse other NGS-based diagnostic tests too.

Primary healthcare providers and billing departments will need to check the updated coding guidelines. You can read a full explanation from the CMS here, including new diagnosis codes.