To Cover or Not to Cover? Prenatal DNA Test Creates Quandary for Payers

By Leslie Small

As genetic tests become increasingly accessible, they're helping transform health care by connecting patients with more personalized diagnoses and treatments. But it's often challenging for health plans to decide whether to pay for them.

One prime example can be found in obstetrics, where cell-free DNA-based noninvasive prenatal testing (NIPT) has been rising in popularity among patients and clinicians alike, yet payers differ in terms of how they cover it.

Part of the popularity of NIPT is due to the fact that it's a simple blood test that allows expecting parents to learn a baby's sex in the first trimester. But the test's main purpose is to analyze maternal and fetal DNA fragments to screen for Down syndrome and other chromosomal abnormalities. Supporters point out — and research verifies — that it's more accurate at screening for Down syndrome than an older, "standard" method of screening, which combines a blood test known as serum screening with a fetal ultrasound.

NIPT is now widely covered for "high-risk" pregnant women, according to the Coalition for Access to Prenatal Screening. Plus, 40 commercial insurers cover NIPT for all pregnant women, including Cigna Corp., Geisinger Health Plan, Anthem, Inc. and slew of regional Blue Cross Blue Shield plans. But many state Medicaid programs and two of the country's largest private insurers — Aetna Inc. and UnitedHealthcare — are not yet on board with paying for all pregnant women to have the test.

According to Blair Stevens, a prenatal expert for the National Society of Genetic Counselors, "insurance coverage has not caught up to the demand" for NIPT. One reason is likely because the newer screening method is more expensive than its older counterpart, she suggests. In addition, while "it's clear that NIPT is a better test for Down syndrome," there's been mixed data on whether it's a better screen for more rare conditions, she adds.

For genetic tests of all varieties, one major issue is there's no single entity like the FDA to evaluate them, says Lon Castle, M.D., chief of molecular diagnostics and specialty drug management at eviCore healthcare. "What we're left with is the health plans and the government agencies doing their best to keep up with these things as they come out and evaluating the evidence and making recommendations on them," he adds.

From Health Plan Weekly