Payers' Views on Insurance Coverage for Confirmatory Diagnostics After a Noncovered Multicancer Early Detection (MCED) Test.

Abstract

Background: Multicancer early detection (MCED) tests are not currently covered by most payers but have begun to emerge in clinical practice. Little is known about whether payers would cover confirmatory diagnostics that are necessary after a positive MCED test. Understanding coverage for confirmatory testing is particularly important for oncology professionals who receive referrals for patients with positive MCED results ordered elsewhere, typically in primary care. Our objective was to examine the views of US private payers on coverage for confirmatory diagnostics after a positive, noncovered MCED test.

Methods: We conducted semistructured interviews with 16 private payers: 8 large national insurers, 5 regional insurers, and 3 organizations providing coverage decision support to insurers. Thematic analysis was complemented by simple frequencies of themes to further describe findings.

Results: Although no payers in our cohort covered MCED, most (63%; 10/16) would cover confirmatory testing after a positive MCED test, although 70% (7/10) would cover it only under specific clinical scenarios (high risk or symptoms). Only a minority (19%; 3/16) would cover repeat confirmatory testing if cancer was not diagnosed. No payer had a formal policy for post-MCED confirmatory testing and only 19% (3/16) planned to establish such a policy. Almost all payers expressed general concerns about patient barriers to confirmatory testing, and most (63%; 10/16) planned to address patient barriers to confirmatory testing if/when MCED is covered, but only 5 payers would consider reducing related patient cost-sharing.

Conclusions: Our findings inform oncology professionals caring for patients with positive MCED results, institutions implementing MCED programs, and payers, policymakers, and researchers addressing MCED challenges. Our study highlights the importance of developing explicit coverage policies for confirmatory diagnostics following a noncovered detection test, as this issue will likely extend beyond MCED for similar novel tests. Patient cost-sharing should be addressed as a national policy issue as MCED adoption grows.