Genetic testing for melanoma

Floridagirl2 · Regular Joined: 19 Jun 2008 Posts: 16

[b]I inquired about genetic testing for melanoma to be done on my mother. My derm said it's not a good idea for me to have genetic testing because insurances may not cover me later. so her doctor looked into it and today they called me and left a message. Supposedly, they sent her papers to a genetics doctor(i said supposedly because I was not informed about a fee). She came back saying that medicare won't cover it because it's very expensive(the genetic test). Well, she never said how much it was nor if we wanted to pay for it ourselves. Now i'm getting the feeling that because my mother is on medicare that her care is not as good as other patients with regular insurance. Has anyone here had experience with medicare? Do you feel treatment is the same as with other insurances? How much is genetic testing? Does anyone know anything about genetic testing?
Thanks[/b]

brainman · Posted: Fri Jun 27, 2008 3:40 pm Post subject: Re: Genetic testing for melanoma

Both of my parents were on Medicare and there are significant limitations to what Medicare will pay. However, my parents were always offered the option to pay for things that Medicare would not cover.

I have a question for you. I am not familiar with a genetics test for Melanoma. Is this test supposed to give you an idea of how likely it is for you to get Melanoma in the future? The US Congress just pasted a bill that would prevent insurance companies from denying you coverage based on any genetics testing.
_________________
Jim
Site Administrator and long-term cancer survivor
1992 Astrocytoma grade 2, left motor strip
2005 Recurrence this time said to be an Oligodendroglioma grade 3, same location.
My Story Part 1: http://cancerforums.net/viewtopic.php?p=7350
My Story Part 2: http://cancerforums.net/viewtopic.php?t=8029
Blog http://jimhawkinsport.blogspot.com/

Floridagirl2 · Regular Joined: 19 Jun 2008 Posts: 16

that's what is bothering me. We haven't been offered the option to pay for things on our own. Now it leaves me wondering if the IL-2 that i had inquired about for my mother was more to do wtih medicare instead of her age or liver status.

as for the melanoma gene test, it is supposed to tell me if my mother has the melanoma gene and assess those risks to me. My mother got melanoma on the sole of her toe and they say that type of melanoma is different from the kind that you get from basking in the sun. That type could be more genetic versus environmental. The thing about the gene is that only a small percentage of people that get melanoma have the mutation. Gee, i hope that made sense. I'm very new to all this.

brainman · Posted: Sat Jun 28, 2008 12:18 am Post subject: Re: Genetic testing for melanoma

In that case, if you know that a treatment is not available due to Medicare not covering it, you should tell the doctor of your willingness to pay for it yourself. Often, doctors just assume that if Medicare (or any health insurance) does not pay for it, the patient will opt not to have it. Express your willingness to pay for the tests and see what they say.
_________________
Jim
Site Administrator and long-term cancer survivor
1992 Astrocytoma grade 2, left motor strip
2005 Recurrence this time said to be an Oligodendroglioma grade 3, same location.
My Story Part 1: http://cancerforums.net/viewtopic.php?p=7350
My Story Part 2: http://cancerforums.net/viewtopic.php?t=8029
Blog http://jimhawkinsport.blogspot.com/

Floridagirl2 · Regular Joined: 19 Jun 2008 Posts: 16

do you think medicare patients get treated different than patients on private insurance such as cigna or bluecross?

brainman · Posted: Sun Jun 29, 2008 10:43 pm Post subject: Re: Genetic testing for melanoma

That is a very complex question with a yes and no answer. "Yes" because some doctors to not accept Medicare patients. Also "Yes" in terms of the limits that Medicare has. However, if the hospital and doctors do accept Medicare patients and if the services needed are covered by Medicare, it would be illegal and unethical to treat Medicare patients differently.
_________________
Jim
Site Administrator and long-term cancer survivor
1992 Astrocytoma grade 2, left motor strip
2005 Recurrence this time said to be an Oligodendroglioma grade 3, same location.
My Story Part 1: http://cancerforums.net/viewtopic.php?p=7350
My Story Part 2: http://cancerforums.net/viewtopic.php?t=8029
Blog http://jimhawkinsport.blogspot.com/

Barbara K · Regular Joined: 11 Apr 2007 Posts: 34

I believe your provider is stating Medicare won't pay for this test because there isn't a specific code in the billing procedure for this specific test and he/she is unaware of the procedure to get approval from Medicare for this test and have it added to the Medicare codes of approved genetic diagnostic tests. The cost of the genetic test itself is not a criteria for Medicare. The criteria for Medicare payment is if the test is for diagnostic purposes.

Refer your provider to the following links for detailed information on Medicare payment criteria for genetic testing and the specific steps your provider must take to get this test approved because it's a non-standard type of skin cancer.

http://www.myriadtests.com/doc/Myriad-ABN.pdf

http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=24308&lcd_version=6

From what I'm seeing here, Medicare would pay for genetic testing on your mom because she already has symptoms etc... of this particular skin cancer and it would be considered a diagnostic test. If your mom has NO symptoms or signs of this cancer, then it's considered a screening test and not eligible for payment approval.

..."If a person is tested to rule out or to confirm a suspected diagnosis because the patient has a sign and/or symptoms, this is considered a diagnostic test, not a screening test. Contractors have discretionary authority to make reasonable and necessary scope of benefit determinations."

..."testing of unaffected family members or other individuals is considered by Medicare to be screening and is not payable under the Medicare program."

[b]However,[/b] because this particular type of skin cancer isn't listed in their codes of approved genetic tests, her physician has to provide adequate documentation to add this type of skin cancer genetic testing to their list of approved codes for payment.

..."The documentation is not required at the time of the initial claim, but may be requested for post-payment review. Documentation must be adequate to verify that coverage guidelines listed above have been met.

The documentation, which must be made available upon request from the laboratory or billing provider, must include personal and family history information consistent with this policy, and a signed informed consent indicating that the patient was informed of the following issues and information:

• cancer risks associated with each possible test result
• likelihood of carrying a gene mutation given the patient's personal and family history (e.g. pedigree analysis)
• implication for family members
• potential adverse effects, benefits, and limitations of testing
• relevant management options such as surveillance, prophylactic surgery, and medical preventive or therapeutic measures if available and risks associated with them.

For these tests, the billing provider must provide to the laboratory copies of the signed informed consent documentation.

The laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition (ICD-9-CM code) that warrants the test.

The documentation must be made available from the billing provider (i.e. the laboratory) upon request by the contractor.

Before furnishing a beneficiary a test which the physician or laboratory believes is excluded from coverage as not reasonable and necessary (rather than excluded from coverage as part of a routine test), the physician or laboratory must obtain a signed Advanced Beneficiary Notice (ABN) from the beneficiary (or representative) that the physician or laboratory has informed him/her of the non-coverage of the test and that there will be a charge for the test. (Medicare Claims Processing Manual, Chapter 16, Section 40.7 - Billing for Noncovered Clinical Laboratory Tests)

NAS must remind all providers requesting new coverage that you must include relevant literature supporting your request.

6. One request was received (which contained numerous supportive articles) requesting that NAS add multiple myeloma to the list of covered conditions for genetic testing.

NAS has added the appropriate diagnosis codes:
203.00 Multiple myeloma without mention of remission
203.01 Multiple myeloma in remission

7. NAS received several requests for the coverage of several conditions,
on the assumption that the testing would be for diagnostic and therapeutic purposes, not screening.

286.3 Congenital deficiency of other clotting factors
289.81 Primary hypercoagulable state
753.13 Polycystic kidney, autosomal dominant
753.14 Polycystic kidney, autosomal recessive
756.51 Osteogenesis imperfecta
756.83 Ehlers-Danlos syndrome
757.1 Ichthyosis congenita
759.83 Fragile X syndrome

NAS has reviewed these conditions and has decided to add coverage for the above conditions so long as they are used for diagnostic and therapeutic purposes, not screening..."

Barbara K.

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