UCSF

Evaluating insurer coverage policies regarding tumor sequencing panels

Next-generation tumor sequencing panels (NGTS) are emerging in oncology practice but a lack of payer coverage could impact access to and adoption of these tests. We conducted the first study of US payers on NGTS coverage and reimbursement, drawing on interviews with experts and ten major payers, representing over 125 million enrollees. Our findings, now in press at the Journal of the National Comprehensive Cancer Network, reveal that payers see potential benefits of NGTS, but all noted challenges to formal coverage:

  • 80 percent stated that NGTS doesn’t meet the medical necessity requirement for coverage,
  • 70 percent view NGTS as a “bundle” of targets versus a comprehensive tumor analysis and may evaluate each target individually,
  • 70 percent express skepticism regarding new evidence methods proposed for NGTS.

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Challenges of coverage policy development for next-generation tumor sequencing panels: experts and payers weigh in

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