Late last week, the Medicare contractor that provides coverage for several states unexpectedly posted a notice on its web site that it would no longer pay for Roche's Avastin medication for treating breast cancer after January 29. But late Friday, Palmetto, which is a subsidiary of BlueCross BlueShield of South Carolina, did an embarassing about face and rescinded its decision (read this).
The move came after the FDA last month began the process of removing the breast cancer indication for the medication following a review that found clinical studies indicated Avastin does not prolong overall survival in breast cancer patients or provide a sufficient benefit in slowing disease progression to outweigh significant risks. At the same time, there were serious side effects (see here).
The Medicare contractor, which also provides coverage in Ohio, West Virginia, Nevada, California and Hawaii, apparently acted too hastily, however. Sources say Palmetto did not go through the usual motions before posting its decision, which was quickly scrubbed from its web site, and allow for public comment. And its action annoyed officials at the Centers for Medicare & Medicaid Services, since Roche's Genentech unit is appealing the decision by the FDA, which assured patients that Medicare would continue to cover Avastin while the appeals process played out.
1 Comment
Exiqon Oncotech depended on Medicare reimbursement to support its business model. In the USA, Medicare coverage decisions for many types of medical services are made at the regional level (Local Coverage Decision or LCD), by the private insurance companies with which Medicare contracts to administer services to Medicare beneficiaries.
Previous Medicare contractors for California made the determination that chemoresponse assays qualified as a Medicare covered service. These included the TransAmerica and National Heritage Insurance (NHIC) companies. Most recently, Palmetto was awarded the contract to administer Medicare services for California. Palmetto made the decision to discontinue Medicare payment for chemoresponse assays in California.
Exiqon Oncotech announced that it discontinued operations (closed shop), because of the withdrawal of Medicare reimbursement for its services. In the case of Exiqon Oncotech's dozens of tumor specimens simply marked "return to sender" it can scarcely be imagined anything more irresponsible.
In many of those cases, doubtless the physicians and/or surgeons discussed in advance with their patients the importance of sending their biopsies for cell culture analysis. In some cases, the surgical procedure may have been performed primarily for the purpose of this analysis. In other cases, the patients were doubtless comforted by knowing that this testing was to be performed. Many are saddened by the shuttering of Oncotech's doors, 25 years after its founding by Drs. Robert Nagouney and Larry Weisenthal, and are ashamed at the way in which those doors were apparently shuttered. The previous CMS administrator for Medicare in Southern California (NHIC) spent almost the entire 2006 doing a extensive, transparent tech assessment of chemoresponse assays and made the decision that the assays were a perfectly appropriate medical service, worthy of coverage on a "non-investigational" basis.
Did Palmetto's indiscriminate action, without having an extensive, transparent tech assessment of the evidence annoy officials at CMS? No! Did Palmetto do an embarassing about face and rescind its decision? No! CMS allowed Palmetto to arbitrarily and capriciously stop reimbursements to cancer patient services. Business is business, but at a certain point, business is also about people and cancer business is about cancer patients.