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CGX Medicare

Apurva Posted Mon 25th of May, 2020 02:45:26 AM
Our understanding of CGX for CMS is that a person must have an active or past qualified cancer diagnosis, with or without family history.If this is not the case please issue guidance on these points . We need to fully understand what we can and cannot accept for CGX to be reimbursed. Accepting personal family history only with family history. No stand alone family history.
SuperCoder Answered Tue 26th of May, 2020 08:33:42 AM

Hi Apurva,

Genetic/Genomic Testing (CGx) being performed for the hereditary conditions and to determine an individual’s risk of developing those condition(s). Some people will inherit the mutations on the germline, which may allow the variation of the mutation to be passed from parents to the children as a hereditary condition. Most of the times, multiple mutations in a person are responsible for most hereditary cancers.

CGx is therefore recommended for most people who have experienced certain personal history of cancers or any pattern of cancer in the family.

On the general medical recommendations, if anyone has had any of the following, then he/she might want to consider CGx testing:

  • Any of the first relatives (father, mother, brothers, sisters, children) coming up with cancer
  • Any of the relatives on the side of immediate family that have had the same type of cancer
  • Cluster of cancer in the family, known to be associated with a single genetic mutation, for example, ovarian, breast and pancreatic cancer in the family.
  • Any family member having more than one type of cancer
  • Any of the close relative having cancer linked to a rare hereditary cancer
  • Any family member having rare cancer, for example, male developing breast cancer
  • During examination (on in old medical report) physical findings linked to an inherited type of cancer
  • Any known mutation in the gene in member(s) of the family that have undergone CGx, etc.

However, Medicare does not have a broad national coverage policy on genetic/Genomic testing. Therefore, local Medicare contractors may make policies that apply only within their own jurisdictions. So, it is suggested to check your applied policy and get to know all the possible requirement for the reimbursement. Also, there are chances to provide the many genomic tests in a single location, i.e. all specimens might send to a single laboratory, the decision of the local contractor having oversight of that laboratory has national implications.

Hope this helps!

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