Increase in Claim Denials for Cancer-Related Advanced Genetic Testing Highlighted in New Study

Recent research published in JAMA Network Open sheds light on a troubling trend: the rising rates of insurance claim denials for cancer-related advanced genetic testing, especially next-generation sequencing (NGS). Despite advancements in genomic technology and the establishment of Medicare coverage standards, there has been a significant increase in the number of claims rejected by insurers from 2016 to 2021.

The study, conducted by researchers from Georgetown University Medical Center, analyzed nearly 30,000 NGS claims filed by close to 25,000 Medicare beneficiaries, revealing that the use of cancer-related NGS testing has nearly quintupled over these years. Interestingly, the claim denial rate climbed from 16.8% in 2018—before the Medicare national coverage determination (NCD)—to an alarming 27.4% in 2021, after the NCD was amended to include testing for hereditary mutations in breast and ovarian cancers.

One notable finding was that claims submitted by independent laboratories were almost twice as likely to be denied compared to hospital-based laboratories. Moreover, tests involving 50 or more genes faced denial rates three times higher than simpler, smaller panels. The median cost of denied claims was around $3,800, underscoring the financial implications for providers and patients. While these denials could hamper access to crucial diagnostic information, the study questions whether the increased costs ultimately lead to better patient outcomes or cost savings through more precise treatments.

The report suggests there may be a lag in adopting the updated coverage policies and a lack of clarity around guidelines in specific circumstances, which contribute to the high denial rates. Dr. So-Yeon Kang emphasizes that ongoing efforts are needed to reduce this uncertainty and ensure patients receive appropriate diagnostic testing.

As NGS technology becomes more integrated into cancer care, understanding and addressing these coverage barriers is essential. Future research aims to investigate whether the benefits of advanced genetic testing translate into reduced overall treatment costs and improved health outcomes for patients.

For more details, see the full study: DOI: 10.1001/jamanetworkopen.2025.5785.

Source: medicalxpress.com