Pressure Building on TriCare Over Noncoverage Of Molecular Diagnostic Testing

Lawmakers and military groups are stepping up the pressure on TRICARE to reverse its noncoverage policies for many molecular diagnostic tests. More than 50 U.S. senators and representatives signed on to a Feb. 27 letter to Chuck Hagel, secretary of defense, expressing concerns regarding TriCare’s change in reimbursement policy. The letter notes that on Jan. 1, 2013, TriCare placed more than 100 molecular pathology (MoPath) tests on the No Government Pay Procedure Code List (NGPPCL) and discontinued reimbursement for these tests. “We are concerned that this policy change was not appropriately communicated to TRICARE beneficiaries or medical providers as [Department of Defense] policy requires,” write the lawmakers. “The [tests] that were placed on the NGPPCL include MoPath tests frequently used to test for diseases or conditions, including those that may develop during a pregnancy (Cystic Fibrosis, Fragile X syndrome, and spinal muscular atrophy).” The letter also notes that certain molecular pathology tests may still be covered for TRICARE beneficiaries who use a military treatment facility (MTF) but that in most cases, those same tests will no longer be covered for beneficiaries who do not have access to an MTF and who use a civilian medical provider. “We are concerned that TRICARE’s decision will jeopardize patient access to [molecular diagnostic tests] and ultimately creates two levels of care within the military health system and the TRICARE network: one that discriminates against beneficiaries with limited access or those unable to access a[n] MTF,” says the letter. According to the American Clinical Laboratory Association (ACLA), TRICARE’s rationale for failing to cover these tests is that they are laboratory-developed tests (LDTs) that are not approved by the Food and Drug Administration. However, many, if not most, molecular diagnostics today are performed as LDTs. In a statement provided to the House Armed Services Committee on Feb. 26, ACLA notes that the molecular tests that TRICARE stopped covering were not new tests in 2013. Rather, they were simply assigned new CPT codes. “In January 2013, all payers switched to new codes identifying the individual test,” says ACLA. “Most payers promptly covered the test utilizing the new codes; however, TRICARE has become an outlier with its persistent policy of noncoverage.” In their Feb. 27 letter to Hagel, lawmakers requested that he respond to several questions, among them:

• What are TRICARE’s policies for providing a notification and public comment period for reimbursement policy changes impacting beneficiaries?
• What stakeholder input and feedback did TRICARE consider?
• What is TRICARE’s justification for denying coverage for LDTs for patients who receive care outside of an MTF but continuing coverage and reimbursement for LDTs provided for patients who receive care within an MTF?
• Does TRICARE have an appeal process for services that a physician determines are medically necessary for a specific patient but that are not covered under current TRICARE policy?

According to Julie Khani, ACLA senior vice president, there has been no official response from TRICARE though officials have indicated they will publish guidance on a demonstration project. “We believe current regulations allow LDTs to be covered; a demonstration project is unnecessary and will result in delays in TRICARE beneficiaries from receiving access to these essential health services,” she says. Takeaway: TRICARE, which provides medical services for military families and retirees, has stopped reimbursing clinical laboratories for molecular pathology testing provided by civilian medical providers. Military groups and lawmakers are pressuring the Defense Department to reverse its noncoverage policy.