Private Payer and Medicare Coverage for Circulating Tumor DNA Testing: A Historical Analysis of Coverage Policies From 2015 to 2019

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  • 1 Department of Clinical Pharmacy, UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), San Francisco;
  • 2 Department of Population Science, and
  • 3 Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte; and
  • 4 UCSF Philip R. Lee Institute for Health Policy, and
  • 5 UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California.
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Background: Clinical adoption of the sequencing of circulating tumor DNA (ctDNA) for cancer has rapidly increased in recent years. This sequencing is used to select targeted therapy and monitor nonresponding or progressive tumors to identify mechanisms of therapeutic resistance. Our study objective was to review available coverage policies for cancer ctDNA–based testing panels to examine trends from 2015 to 2019. Methods: We analyzed publicly available private payer policies and Medicare national coverage determinations and local coverage determinations (LCDs) for ctDNA-based panel tests for cancer. We coded variables for each year representing policy existence, covered clinical scenario, and specific ctDNA test covered. Descriptive analyses were performed. Results: We found that 38% of private payer coverage policies provided coverage of ctDNA-based panel testing as of July 2019. Most private payer policy coverage was highly specific: 87% for non–small cell lung cancer, 47% for EGFR gene testing, and 79% for specific brand-name tests. There were 8 final, 2 draft, and 2 future effective final LCDs (February 3 and March 15, 2020) that covered non–FDA-approved ctDNA-based tests. The draft and future effective LCDs were the first policies to cover pan-cancer use. Conclusions: Coverage of ctDNA-based panel testing for cancer indications increased from 2015 to 2019. The trend in private payer and Medicare coverage is an increasing number of coverage policies, number of positive policies, and scope of coverage. We found that Medicare coverage policies are evolving to pan-cancer uses, signifying a significant shift in coverage frameworks. Given that genomic medicine is rapidly changing, payers and policymakers (eg, guideline developers) will need to continue to evolve policies to keep pace with emerging science and standards in clinical care.

Submitted October 11, 2019; accepted for publication January 29, 2020.

Author contributions: Study concept or design: Douglas, Phillips. Data acquisition, analysis, or interpretation: All authors. Manuscript preparation or critical revision: All authors.

Disclosures: Mr. Douglas has disclosed that he receives consulting fees from Illumina, Inc. Dr. Gray has disclosed that she has not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article. Dr. Phillips has disclosed that she receives consulting fees from Illumina, Inc., and received consulting fees from Lexent Bio, Inc.

Funding: This work was supported by grants from the National Cancer Institute (R01 CA221870) and the National Human Genome Research Institute (U01 HG009599) to Dr. Phillips.

Disclaimer: The National Human Genome Research Institute and the National Cancer Institute had no role in the preparation, review, or approval of the manuscript or decision to submit the manuscript for publication.

Correspondence: Michael P. Douglas, MS, Department of Clinical Pharmacy, UCSF Center for Translational and Policy Research on Personalized Medicine, 3333 California Street, Room 420, Box 0613, San Francisco, CA 94143. Email: michael.douglas@ucsf.edu

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