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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that providers must report services correctly. Procedures should be reported with the CPT code that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I(A). The rules say that coverage will continue on a case by case basis utilizing the following criteria until such time a more comprehensive non-proprietary local coverage determination can be developed. Guardant360 remains covered for patients with non-CNS originated solid tumors who meet the criteria of NCD 90.2 when the following conditions are met: Patient has been diagnosed with a recurrent, relapsed, refractory, metastatic, or advanced solid tumor that did not originate from the central nervous system. Patients who would meet all of the indications on the FDA label for larotrectinib if they are found to have an NTRK mutation may be considered to have advanced cancer, and Patient has not previously been tested with the Guardant360 test for the same primary cancer. For a patient who has been tested previously using Guardant360 for a cancer, that patient may only be tested again when the patient has a new primary cancer diagnosis. In a patient with previously tested primary cancer, who has evidence of new malignant growth, that growth may be considered to be a different primary cancer if it does not originate from the same cell line or it is physiologically different enough that it responds differently to treatment than the previously tested cancer, and Patient is untreated for the primary cancer being tested or the patient is not responding to treatment (e.g. progression or new lesions on treatment), and The patient has decided to seek further cancer treatment with the following conditions: The patient is a candidate for further treatment with a drug that is either FDA-approved for that patient's cancer, or has an NCCN 1 or NCCN 2A recommendation for that patient's cancer, and The FDA-approved indication or NCCN recommendation is based upon information about the presence or absence of a genetic biomarker tested for in the Guardant360 assay, and Tissue-based CGP is infeasible (i.e., quantity not sufficient for tissue-based CGP or invasive biopsy is medically contraindicated) or specifically in NSLC Tissue-based CGP has shown no actionable mutations. If no alteration is detected by Guardant360 or if ctDNA is insufficient/not detected, tissue-based genotyping should be considered. In order to provide a more generic, non-proprietary coverage for plasma based genomic profiling and cell free DNA rejection technology, Noridian is retiring the following policies effective May 15, 2020: Guardant 360 and Prospera. Coverage will continue on a case by case basis utilizing the following criteria until such time a more comprehensive non-proprietary local coverage determination can be developed.
The coverage criteria are as follows: Guardant360 remains covered for patients with non-CNS originated solid tumors who meet the criteria of NCD 90.2 when the following conditions are met: Patient has been diagnosed with a recurrent, relapsed, refractory, metastatic, or advanced solid tumor that did not originate from the central nervous system. Patients who would meet all of the indications on the FDA label for larotrectinib if they are found to have an NTRK mutation may be considered to have advanced cancer, and Patient has not previously been tested with the Guardant360 test for the same primary cancer. For a patient who has been tested previously using Guardant360 for a cancer, that patient may only be tested again unless when the patient has a new primary cancer diagnosis. In a patient with previously tested primary cancer, who has evidence of new malignant growth, that growth may be considered to be a different primary cancer if it does not originate from the same cell line or it is physiologically different enough that it responds differently to treatment than the previously tested cancer, and Patient is untreated for the primary cancer being tested or the patient is not responding to treatment (e.g. progression or new lesions on treatment), and The patient has decided to seek further cancer treatment with the following conditions: The patient is a candidate for further treatment with a drug that is either FDA-approved for that patient's cancer, or has an NCCN 1 or NCCN 2A recommendation for that patient's cancer, and The FDA-approved indication or NCCN recommendation is based upon information about the presence or absence of a genetic biomarker tested for in the Guardant360 assay, and Tissue-based CGP is infeasible (i.e., quantity not sufficient for tissue-based CGP or invasive biopsy is medically contraindicated) or specifically in NSLC Tissue-based CGP has shown no actionable mutations. If no alteration is detected by Guardant360 or if ctDNA is insufficient/not detected, tissue-based genotyping should be considered. Prospera Assay will be covered only when the following clinical conditions are met: When Prospera is utilized to supplement the evaluation and management of kidney injury and active rejection (AR) in patients who have undergone renal transplantation wherein the results will inform decision making supplementing standard clinical assessments and intervention in: First time renal allograft recipients, and Physician-assessed pretest need to further evaluate patient for the probability of active renal allograft rejection. Links for the Billing and Coding articles for each product will be posted when viewable in the Medicare Coverage Database. Noridian will work with the CMS MolDX contractor to facilitate the future comprehensive LCD. You can find this information in Medicare's Local Coverage Article: Billing and Coding: Guardant360 (A58192) and RETIRED Local Coverage Article: Guardant360 and Prospera (A58190).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.