Husband’s oncologist ordered Guardant Reveal blood test, without his knowledge, just done as part of p a weekly blood draw. We received a notice thar insurance company has denied payment, and that cost is $5000 (!), but they are appealing. He always signs paperwork prior to blood draw, has never been charged, and no one pointed this out to him! I thought a Medicare ABN had to be explained/signed prior to tests ordered but Medicare deems not medically necessary due to pt’s condition (dx) so that the patient might responsible for payment. Very disturbing!
Husband’s oncologist ordered Guardant Reveal blood test, without his knowledge, just done as part of p a weekly blood draw. We received a notice thar insurance company has denied payment, and that cost is $5000 (!), but they are appealing. He always signs paperwork prior to blood draw, has never been charged, and no one pointed this out to him! I thought a Medicare ABN had to be explained/signed prior to tests ordered but Medicare deems not medically necessary due to pt’s condition (dx) so that the patient might responsible for payment. Very disturbing!
@abob, I agree that he should have been presented with information on the potential for denial. The companies that perform these types of tests are familiar with dealing with denials, so this isn't over yet, and unfortunately denials are common.
When I was first diagnosed, I was obviously stage IV and my husband's insurance still denied the claim. The performing lab contacted me, I signed an authorization to allow them to appeal the denial on my behalf. I never heard from them again. Either it got paid, or the company waived the charge.
Be patient, it may take some time to work out, but hopefully you won't be left with a bill.
(Link to the CMS page with biomarker info: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=372)
In some cases these test results can significantly alter treatment plans. Are his results back yet? Were there any significant findings from the test?
@abob, I agree that he should have been presented with information on the potential for denial. The companies that perform these types of tests are familiar with dealing with denials, so this isn't over yet, and unfortunately denials are common.
When I was first diagnosed, I was obviously stage IV and my husband's insurance still denied the claim. The performing lab contacted me, I signed an authorization to allow them to appeal the denial on my behalf. I never heard from them again. Either it got paid, or the company waived the charge.
Be patient, it may take some time to work out, but hopefully you won't be left with a bill.
(Link to the CMS page with biomarker info: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=372)
In some cases these test results can significantly alter treatment plans. Are his results back yet? Were there any significant findings from the test?
Report showed only 0.091% detectable which is/was great. And happily the more recent CT showed adrenal mass is now undetectable.
( So did the patient really need the 1 snapshot in time Gardant $5K test to be paid for by Medicare or us for his care? Since his cancer specialist is also a research group if done for research purposes, does this raise a payment responsibility issue?)
Nonetheless, oncologist is recommending adrenalectomy due to any pesky remaining chemo specs. Then probably immunotherapy.
Ahhhh! This is an interesting topic.
Certain tests require Medicare medical necessity, meaning pt has a matching condition / diagnosis code.
This is part of the government’s requirement to ascertain that Medicare, which is paid for by our nation’s working contributors, is fairly charged. These policies are defined in National and Local Coverage Determinations (NCD, LCD) and are found on Medicare.gov. Medicare ads/deletes/updates policies and codes often.
If a test is not justified by a policy, patient should be given an Advance Beneficiary Notification (ABN) explaining this. If pt agrees and signs, pt will be billed. If pt refuses to sign but still wants the test, a witness signs to this effect, and pt will be billed. Or pt can refuse test.
Often clinician did not add pt’s justifiable dx code to the order. Sometimes the policy has complicated restrictions. Thus it is difficult for patients,, clinicians, providers, but it is a “necessity”.
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Husband’s oncologist ordered Guardant Reveal blood test, without his knowledge, just done as part of p a weekly blood draw. We received a notice thar insurance company has denied payment, and that cost is $5000 (!), but they are appealing. He always signs paperwork prior to blood draw, has never been charged, and no one pointed this out to him! I thought a Medicare ABN had to be explained/signed prior to tests ordered but Medicare deems not medically necessary due to pt’s condition (dx) so that the patient might responsible for payment. Very disturbing!
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1 ReactionWow! So sorry. I honestly have operated on the premise that if the dr seems it medically necessary, Medicare would pay.
@abob, I agree that he should have been presented with information on the potential for denial. The companies that perform these types of tests are familiar with dealing with denials, so this isn't over yet, and unfortunately denials are common.
When I was first diagnosed, I was obviously stage IV and my husband's insurance still denied the claim. The performing lab contacted me, I signed an authorization to allow them to appeal the denial on my behalf. I never heard from them again. Either it got paid, or the company waived the charge.
Be patient, it may take some time to work out, but hopefully you won't be left with a bill.
(Link to the CMS page with biomarker info: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=372)
In some cases these test results can significantly alter treatment plans. Are his results back yet? Were there any significant findings from the test?
Thx for your helpful reply. Gardant is appealing and our Oncology group is assisting with the appeal.
Gardant published this last year:
https://investors.guardanthealth.com/press-releases/press-releases/2023/Guardant-Health-Receives-Medicare-Coverage-for-Guardant360-Response-to-Monitor-Cancer-Patient-Response-to-Immunotherapy/default.aspx
Local Coverage Determination (LCD)
MolDX: Plasma-Based Genomic Profiling in Solid Tumors: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=38043
Criteria for Coverage: Guardant360® is covered only when all of the following conditions are met:
QUITE A DETAILED LIST!
Report showed only 0.091% detectable which is/was great. And happily the more recent CT showed adrenal mass is now undetectable.
( So did the patient really need the 1 snapshot in time Gardant $5K test to be paid for by Medicare or us for his care? Since his cancer specialist is also a research group if done for research purposes, does this raise a payment responsibility issue?)
Nonetheless, oncologist is recommending adrenalectomy due to any pesky remaining chemo specs. Then probably immunotherapy.
Ahhhh! This is an interesting topic.
Certain tests require Medicare medical necessity, meaning pt has a matching condition / diagnosis code.
This is part of the government’s requirement to ascertain that Medicare, which is paid for by our nation’s working contributors, is fairly charged. These policies are defined in National and Local Coverage Determinations (NCD, LCD) and are found on Medicare.gov. Medicare ads/deletes/updates policies and codes often.
If a test is not justified by a policy, patient should be given an Advance Beneficiary Notification (ABN) explaining this. If pt agrees and signs, pt will be billed. If pt refuses to sign but still wants the test, a witness signs to this effect, and pt will be billed. Or pt can refuse test.
Often clinician did not add pt’s justifiable dx code to the order. Sometimes the policy has complicated restrictions. Thus it is difficult for patients,, clinicians, providers, but it is a “necessity”.