GLN173-Oncotype-Prostate-Score-Assay_Prolaris-81479_81541
Prostate Cancer Gene Expression tests billed with nonspecific codes (e.g. 81479, 81599, 84999)?Oncotype DX Genomic Prostate Score?Decipher RP for prostate cancer81541 Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping)Last reviewed at VbBS in March 2021. Minutes indicate that the staff recommendation was accepted without significant discussion. HERC approved the recommendations without change. EvidenceAHRQ 2020, Therapies for Clinically Localized Prostate CancerN=17 RCTsKey question: How do tumor characteristics modify comparative effectiveness and harms of CLPC therapies? Biomarker Status Decipher (Genomic Classifier)Oncotype Dx (Genomic Prostate Score) Prolaris (Cell Cycle Progression) We found no evidence that met our predefined inclusion criteria for the newer prognostic (proprietary) biomarkers such as Decipher, Oncotype Dx and Prolaris as it relates to comparative effectiveness modificationWashington HTA 2018, Gene expression profile testing of cancer tissueN=8 studies regarding prostate cancer, all rated high risk of biasFor Oncotype DX and Prolaris, however, there were consistent findings associating the use of the tests with decreased treatment intensity. Two studies on the Prolaris test found that for between 40% and 70% of patients, the recommended or actual treatments were less invasive or intensive with the use of the test than before test results were available. Similar results were reported for all four of the Oncotype DX studies, which found that more men had recommendations for watchful waiting or active surveillance rather than more intensive forms of treatment in three of the studiesThe magnitude of these changes to noninvasive forms of treatment varied by study, but ranged from 21% to 51% of subjects compared to the group without the test. The fourth study reported that treatment intensity decreased for 15.8%, increased for 8.9% and was unchanged for 38.7%.No studies found on impact of any of these tests on mortality or morbidityVery low evidence found regarding patient management decisionsVery low evidence found on impact on quality of lifeNo evidence found on harmsLow evidence found on cost-effectivenessThe overall quality of evidence for these findings is very low because of substantial limitations, including use of before-after designs and recommended rather than actual treatments, in addition to the lack of important patient outcomes such as survival or treatment-related morbidity.Conclusion: There is a mix of low-quality, very low-quality, and no evidence to support the other included tests for prostate cancer, colon cancer, and multiple myeloma. Multiple ongoing clinical trials on most of the tests will be reporting results in the next few years and will hopefully improve the evidence base for decision making regarding the clinical usefulness and economic effects of these tests.Expert guidelinesNCCN 2020, Prostate CancerInitial risk stratification and staging workup for clinically localized diseaseFor low risk for favorable intermediate risk men with life expectancy ≥ 10 yrs, the NCCN algorithm branches are radiation, surgery or active surveillance. If active surveillance is chosen, then patients should be followed with PSA and repeat prostate biopsy no more than once per year. To enter this pathway, clinicians and patients can “consider mpMRI and/or prostate biopsy and/or molecular tumor analysis to confirm candidacy for active surveillance.”Therefore, molecular tumor analysis is not required to enter the active surveillance pathway. Furthermore, if a patient is considering active surveillance, molecular assays are only one option to give information on a patient’s candidacyThe footnote regarding molecular assays states: “Men with low or favorable intermediate-risk disease and life expectancy ≥ 10 yrs may consider the use of the following tumor-based molecular assays: Decipher, Oncotype DX Prostate, Prolaris, and Promark” [emphasis HERC staff]Other payer policiesWashington Medicaid:Changed coverage policy with 2019 review to cover: Prostate cancer tests Oncotype DX and Prolaris are covered only for low risk or favorable intermediate risk disease. Prostate cancer test Decipher is covered for men deciding between active surveillance and adjuvant radiotherapy after radical prostatectomy. Coverage change appears to be based on Medicaid LCDs, ASCO and NCCN recommendationsAetna 2021, BiomarkersOncotype DX Prostate for the following indications post biopsy:men with NCCN very-low-risk, low-risk, and favorable intermediate-risk prostate cancer who have greater than 10 year life expectancy and who have not received treatment for prostate cancer and are candidates for active surveillance or definitive therapy; ormen with intermediate-risk prostate cancer when deciding whether to add androgen-deprivation therapy to radiation.NOTE: this is a change from the coverage policy (investigational) in place during the coverage guidance reviewEvicore 2021, Oncotype DX for Prostate CancerThis test (oncotype dx prostate cancer) is considered investigational and/or experimentalInvestigational and experimental (I&E) molecular and genomic (MolGen) tests refer to assays involving chromosomes, DNA, RNA, or gene products that have insufficient data to determine the net health impact, which typically means there is insufficient data to support that a test accurately assesses the outcome of interest (analytical and clinical validity), significantly improves health outcomes (clinical utility), and/or performs better than an existing standard of care medical management option. Such tests are also not generally accepted as standard of care in the evaluation or management of a particular condition HERC staff summarySince the 2017-2018 review, new systematic reviews from trusted sources (AHRQ, WA HTA) have not found evidence to support the use of biomarkers for prostate cancer, including Decipher (CPT 81542), Oncotype DX Prostate, and Prolaris (CPT 81541). However, Washington Medicaid felt there was enough evidence from the HTA review to change coverage policy, with their discussion mainly centered around expert guideline recommendations. Additionally, some private payers have changed their coverage policies since the coverage guidance review, generally to align with NCCN. The NCCN guideline however does not require gene expression testing to determine eligibility for active surveillance. HERC staff recommendation:Update GN173 entry for prostate cancer gene expression tests as shown belowUpdates review dateStandardizes rationale statementCPT 81541 is used for Prolaris; CPT 81542 is used for DecipherGUIDELINE NOTE 173, INTERVENTIONS THAT ARE UNPROVEN, HAVE NO CLINICALLY IMPORTANT BENEFIT OR HAVE HARMS THAT OUTWEIGH BENEFITS FOR CERTAIN CONDITIONSLine 662The following Interventions are prioritized on Line 662 CONDITIONS FOR WHICH CERTAIN INTERVENTIONS ARE UNPROVEN, HAVE NO CLINICALLY IMPORTANT BENEFIT OR HAVE HARMS THAT OUTWEIGH BENEFITS:Procedure CodeIntervention DescriptionRationaleLast ReviewProstate Cancer Gene Expression tests billed with nonspecific codes (e.g. 81479, 81599, 84999)Oncotype DX Genomic Prostate ScoreDecipher RP for prostate cancerUnproven InterventionInsufficient evidence of effectivenessJanuary, 2018 March 2021Coverage guidance81541Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping)Unproven InterventionInsufficient evidence of effectivenessAugust, 2015March 202181542Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk scoreInsufficient evidence of effectivenessJanuary 2018March 2021Modify GN148 as shown belowAdds CPT code for ProlarisGUIDELINE NOTE 148, BIOMARKER TESTS OF CANCER TISSUELines 157,?184,?191,?229,?262,?271,?329The use of tissue of origin testing (e.g. CPT 81504) is included on Line 662 CONDITIONS FOR WHICH CERTAIN INTERVENTIONS ARE UNPROVEN, HAVE NO CLINICALLY IMPORTANT BENEFIT OR HAVE HARMS THAT OUTWEIGH BENEFITS. For early stage breast cancer, the following breast cancer genome profile tests are included on Line 191 when the listed criteria are met. One test per primary breast cancer is covered when the patient is willing to use the test results in a shared decision-making process regarding adjuvant chemotherapy. Lymph nodes with micrometastases less than 2 mm in size are considered node negative.Oncotype DX Breast Recurrence Score (CPT 81519) for breast tumors that are estrogen receptor positive, HER2 negative, and either lymph node negative, or lymph node positive with 1-3 involved nodes.EndoPredict (CPT 81522) and Prosigna (CPT 81520 or PLA 0008M) for breast tumors that are estrogen receptor positive, HER2 negative, and lymph node negative.MammaPrint (using CPT 81521 or HCPCS S3854) for breast tumors that are estrogen receptor or progesterone receptor positive, HER2 negative, lymph node negative, and only in those cases categorized as high clinical risk.EndoPredict, Prosigna, and MammaPrint are not included on Line 191 for early stage breast cancer with involved axillary lymph nodes. Oncotype DX Breast Recurrence Score is not included on Line 191 for breast cancer involving four or more axillary lymph nodes or more extensive metastatic disease. Oncotype DX Breast DCIS Score (CPT 81479) and Breast Cancer Index (CPT 81518) are included on Line 662 CONDITIONS FOR WHICH CERTAIN INTERVENTIONS ARE UNPROVEN, HAVE NO CLINICALLY IMPORTANT BENEFIT OR HAVE HARMS THAT OUTWEIGH BENEFITS.For melanoma, BRAF gene mutation testing (CPT 81210) is included on Line 229.For lung cancer, epidermal growth factor receptor (EGFR) gene mutation testing (CPT 81235) is included on Line 262 only for non-small cell lung cancer. KRAS gene mutation testing (CPT 81275) is not included on this line. For colorectal cancer, KRAS gene mutation testing (CPT 81275) is included on Line 157. BRAF (CPT 81210) and Oncotype DX are not included on this line. Microsatellite instability (MSI) is included on the Line 662.For bladder cancer, Urovysion testing is included on Line 662.For prostate cancer, Oncotype DX Genomic Prostate Score, Prolaris Score Assay (CPT 81541), and Decipher Prostate RP (CPT 81542) are included on Line 662.The development of this guideline note was informed by a HERC coverage guidance on Biomarkers Tests of Cancer Tissue for Prognosis and Potential Response to Treatment; the prostate-related portion of that coverage guidance was superseded by a Coverage Guidance on Gene Expression Profiling for Prostate Cancer. See January, 2018, these new CPT codes were placed on Guideline Note 173 and attached to line 660.Adapted from 1/18/2018 Meeting Materials. Minutes indicate the recommendation was accepted with minimal discussion. 81479 Oncotype DX Genomic Prostate Score Assay, Decipher Prostate RP81541 Prolaris. Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR?of 46 genes (31 content and 15?housekeeping)Question: How should the draft Coverage Guidance on Gene Expression Profiling for Prostate Cancer be applied to the Prioritized List?Question source: HERC Staff, HTASIssue: The HTAS approved the following draft “box language”:DRAFT HERC Coverage GuidanceGene expression profiling tests for prostate cancer (including Prolaris, Oncotype DX, and Decipher) are not recommended for coverage (strong recommendation).Rationale for Recommendations:Accurate risk stratification is important for effective clinical management of prostate cancer, to avoid unnecessary invasive treatment. Oncotype DX and Prolaris can be used after an initial diagnosis of prostate cancer, to predict the cancer’s aggressiveness, and thereby inform decision making on treatment versus active surveillance. Decipher can be used after a radical prostatectomy to predict the probability of metastasis, and thus inform clinical decisions on the potential use of additional (adjuvant) radiation therapy.The published evidence on gene expression profiling tests for prostate cancer (including Prolaris, Oncotype DX, and Decipher) is currently limited to observational studies on treatment decision changes only. Overall, these studies provide very low confidence that gene expression testing results in changes to prostate cancer management plans. None of the published clinical utility studies provide information on the effects of these tests on clinical outcomes from prostate cancer.? Evidence is insufficient for critical and important outcomes, including the effects of test utilization on prostate cancer morbidity and mortality or quality of life. In the absence of clinical outcomes evidence, treatment cost savings can be theorized, but not established.?These tests are at the beginning of the validation pathway. Future research may allow these tests to gain additional evidence regarding their clinical utility for better risk stratification of men with prostate cancer.Current Prioritized List Status: CodesPrior to 2018, CPT 81479 (unlisted molecular pathology procedure) was used for these three prostate gene expression tests (Oncotype DX, Prolaris, Decipher). This non-specific procedure code does not appear on the Prioritized List.A new 2018 CPT code (81541) is now available to use for Prolaris. HERC placed this code on Line 660 for the January 1, 2018 Prioritized List, based on a previous coverage guidance.Current Prioritized List Guideline:GUIDELINE NOTE 148, BIOMARKER TESTS OF CANCER TISSUE?Lines 157,184,191,230,263,271,329?The use of multiple molecular testing to select targeted cancer therapy (CPT 81504) is included on the Services recommended for non-coverage table.?For breast cancer, Oncotype Dx testing (CPT 81519, HCPCS S3854) is included on Line 191 only for early stage breast cancer when used to guide adjuvant chemotherapy treatment decisions for women who are lymph node negative. Oncotype Dx is not included on this line for lymph node-positive breast cancer. Mammaprint, ImmunoHistoChemistry 4 (IHC4), and Mammostrat for breast cancer are included on the Services recommended for noncoverage table.?For melanoma, BRAF gene mutation testing (CPT 81210) is included on Line 230.?For lung cancer, epidermal growth factor receptor (EGFR) gene mutation testing (CPT 81235) is included on Line 263 only for non-small cell lung cancer. KRAS gene mutation testing (CPT 81275) is not included on this line.?For colorectal cancer, KRAS gene mutation testing (CPT 81275) is included on Line 157. BRAF (CPT 81210) and Oncotype DX are not included on this line. Microsatellite instability (MSI) is included on the Services recommended for noncoverage table.?For bladder cancer, Urovysion testing is included on Services recommended for noncoverage table.For prostate cancer, Oncotype DX is not included on Line 329 and Prolaris is included on the Services recommended for noncoverage table.?The development of this guideline note was informed by a HERC coverage guidance. See Staff Recommendation:Affirm placement of Prolaris (CPT 81541) on Line 660, and add Oncotype DX and Decipher (utilizing CPT 81479) to Line 660. Add an entry to GN 173 as shown below:GUIDELINE NOTE 173, INTERVENTIONS THAT ARE UNPROVEN, HAVE NO CLINICALLY IMPORTANT BENEFIT OR HAVE HARMS THAT OUTWEIGH BENEFITS FOR CERTAIN CONDITIONS The following interventions are prioritized on Line 660 CONDITIONS FOR WHICH CERTAIN INTERVENTIONS ARE UNPROVEN, HAVE NO CLINICALLY IMPORTANT BENEFIT OR HAVE HARMS THAT OUTWEIGH BENEFITS:Procedure CodeIntervention DescriptionRationaleLast Review81504Biomarker tests for tumor tissue: Mammaprint, Mammostrat and ImmunoHistoCHemistry 4 (IHC4) for breast cancerMicrosatellite instability (MSI) for colorectal cancer Urovysion for bladder cancerProlaris for prostate cancerMultiple molecular testing to select targeted cancer therapyInsufficient evidence of effectiveness. More costly than equally effective therapies for this conditionAugust, 2015Coverage Guidance Blog…8154181479Prolaris. Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR?of 46 genes (31 content and 15?housekeeping)Oncotype DX Genomic Prostate Score Assay, Decipher Prostate RPUnproven interventionsJanuary, 2018Coverage Guidance BlogRevise Guideline Note 148, as follows:GUIDELINE NOTE 148, BIOMARKER TESTS OF CANCER TISSUELines 157,?184,?191,?230,?263,?271,?329The use of multiple molecular testing to select targeted cancer therapy (CPT 81504) is included on the Services recommended for non-coverage table. For breast cancer, Oncotype Dx testing (CPT 81519, HCPCS S3854) is included on Line 191 only for early stage breast cancer when used to guide adjuvant chemotherapy treatment decisions for women who are lymph node negative. Oncotype Dx is not included on this line for lymph node-positive breast cancer. Mammaprint, ImmunoHistoChemistry 4 (IHC4), and Mammostrat for breast cancer are included on the Services recommended for noncoverage table.For melanoma, BRAF gene mutation testing (CPT 81210) is included on Line 230.For lung cancer, epidermal growth factor receptor (EGFR) gene mutation testing (CPT 81235) is included on Line 263 only for non-small cell lung cancer. KRAS gene mutation testing (CPT 81275) is not included on this line. For colorectal cancer, KRAS gene mutation testing (CPT 81275) is included on Line 157. BRAF (CPT 81210) and Oncotype DX are not included on this line. Microsatellite instability (MSI) is included on the Services recommended for noncoverage table.For bladder cancer, Urovysion testing is included on Services recommended for noncoverage table.For prostate cancer, Oncotype DX Genomic Prostate Score, Prolaris Score Assay, and Decipher Prostate RP are included on Line 660. For prostate cancer, Oncotype DX is not included on Line 329 and Prolaris is included on the Services recommended for noncoverage table.The development of this guideline note was informed by a HERC coverage guidance. See . ................
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