The evidence for supporting such tests is out there for all carriers, yet some say “Yes, we’ll cover it” while others say “No, we won’t” — all while citing the same studies as the basis of their conflicting coverage decisions. When insurers do cover WGS, it tends to be “rapid” WGS for critically ill NICU patients. The value of WGS is recognized in this time-critical environment, while it is simultaneously dismissed as experimental for pediatric and adult patients who would similarly benefit.
Inadequacies in detail regardingprocedure and reimbursem*nt coding is often described as a second barrier to coverage because it hinders insurance companies from easily evaluating what type of genetic test was performed and whether that test was warranted. To be fair, this can be said about most tests that are being reimbursed today. Yes, it might be difficult and laborious to evaluate, but coding for molecular genetic testing, like WGS, needs to become more granular.
Gatekeepers
More insurers are using genetic benefit managers and lab benefit managers to act as gatekeepers for advanced genetic tests and they are requiring more information upfront on what tests are being provided. As the codes become more descriptive and additional information is more routinely submitted, managers will be able to make more accurate reimbursem*nt decisions.
Some medical directors continue to cling to outdated views of genetic testing, denying WGS coverage despite a continuous stream of supporting clinical validation studies.
One of the most common misconceptions is that widely available, low cost, direct-to-consumer genetic tests provide all the information that an individual could need about their genome. In most cases, the technologies used for these tests are in no way equivalent to WGS — covering only a fraction of the individual’s DNA. When an individual requires diagnosis of an inherited disorder, direct-to-consumer tests are not a substitute for the insurance provider’s genetic testing policy.
What to Do Now
What is most needed is education along with a uniform framework and guideline that insurers work from to evaluate whether to cover a technology or not. The data supporting WGS is out there. More clinical cases are being resolved thanks to its use, many of which have fallen through the cracks of the system following multiple costly, less comprehensive genetic tests. Physicians are seeing this and are quicker to acknowledge the utility of these tests and to introduce them into their testing arsenal.
It is widely known and accepted that that when physicians are able to make decisions about what is applicable and appropriate for patients, better outcomes follow. Until coverage and reimbursem*nt of WGS becomes commonplace, if you want to ensure access to top-notch health care, it will continue to be important to take a close look at the carrier’s approach to genetic testing when evaluating insurance policies.
Daryl Spinner is vice president of market access and reimbursem*nt for Variantyx,a genome sequencing company.
