Aim: Commercial plan coverage policies for multigene panel tests may vary and could result in geographic variation in coverage due to the fragmented nature of the commercial insurance market. This study aimed to characterize the alignment of multigene panel tests coverage policies to that of clinical guidelines, overall and by state. Materials & methods: We reviewed NCCN Guidelines® for four tumors. Public coverage policies were identified via web search. Payer policies included those with the largest or second largest number of commercial lives in each state. Policies were classified as 'more restrictive' or 'consistent' with the guidelines. Results: Of 38 plans/policies reviewed, 71% were classified as 'more restrictive' than the guidelines, with variation in the number of commercial lives by state. Among these, 52% restricted on panel size and 63% restricted in all or select tumors. Conclusion: Most coverage policies were more restrictive. Clinical guideline clarity and state policies may improve alignment to guidelines and geographic variations.
Keywords: clinical guidelines; coverage policies; multigene panel tests; next-generation sequencing.
The level of coverage provided by commercial plan policies for tests that simultaneously assess multiple genes for cancer (multigene panel tests) may vary, and the availability of these tests differs depending on geographic location. This may be due to the variable nature of the commercial insurance market. This study aimed to understand how well aligned the coverage for multigene panel tests provided by insurance policies is with recommendations from clinical guidelines, both overall and by US state. NCCN Guidelines® for four cancer types were reviewed and public insurance coverage policies were identified via internet searches. The insurance policies included those with the largest or second largest number of commercial lives in each state. Policies were judged to be either ‘more restrictive’ or ‘consistent’ with the clinical guidelines. Of the 38 plans/policies we reviewed, almost three-quarters (71%) were judged to be ‘more restrictive’ than the guidelines, with differences in the number of commercial lives by state. About half (52%) were restricted on the number of genes to be tested and almost two-thirds (63%) restricted in all or select types of cancer. We found that most insurance policies were more restrictive than the guidelines – therefore covering fewer genes in each test, a different set of genes in each test or restricted to certain types of cancer. Clearer clinical guideline and state policies may help to improve alignment to guidelines and geographic differences.