Does Health Insurance Cover the Cost of the Oncotype DX® Test?

Does Health Insurance Cover the Cost of the Oncotype DX® Test?


Jay K. Harness: When I ordered the Oncotype
DX test, my patients are naturally concerned whether their insurance will cover the cost
of the test. Let me go through the individual indications for the test and then address
the issue of insurance coverage. The most common breast cancer in the United States
is estrogen receptor positive lymph node negative breast cancer. NCCN Guidelines call for the
use of the Oncotype DX test in set of circumstances, Medicare fully covers the cost of the test
and virtually all the major insurance carriers also cover the cost of the test and estrogen
receptor positive lymph node negative breast cancer patients. The second indication in
my practice and most all that I know is the indication for estrogen receptor positive
lymph node positive breast cancers. Here, we are talking about anywhere from one up
to three positive lymph nodes. Once again, this is not covered under NCCN Guidelines
and also by Medicare. The NCCN Guidelines are the kind of guidance that insurance companies
use to determine whether they’re going to pay for things in the world of cancer treatment.
The coverage by insurance carriers other than Medicare in lymph node positive patients varies,
but on appeal virtually most all the time this is covered and rarely when a patient
have to bear the cost on a personal basis. There are mechanisms for handling it the coverage
of the test if an insurance company for whatever reason decides to turn it down. Now, the most
recent indication for the Oncotype test is in situ breast cancer, ductal carcinoma in
situ DCIS and here many of the insurance companies have not officially embraced this. However,
they are able to cover the cost of the Oncotype test and DCIS under umbrella coverages that
they have for lymph node negative invasive breast cancer, so in the vast majority of
cases, you don’t have to worry about the insurance coverage for the Oncotype DX test. There are
appeal mechanisms, the company of course works with individuals and in my experience almost
rarely is the coverage not provided or rarely does the patient have to cover the cost themselves. Michael Alvarado: Did you know that not every
breast cancer patient needs chemotherapy. In fact today, there is a way to identify
whether or not you would benefit from that chemotherapy based on the biology of your
tumor. To learn more about the Oncotype DX assay and how to discuss the results with
your physician, just press this button.

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