A Double Standard on Transplant Tests

Originally published in the Wall Street Journal.

Medicare won’t cover kidney monitoring that a private insurer considers to be ‘medically necessary.’

Government healthcare rationing tends to operate under the radar, but there’s a glaring double standard on display in the case of kidney transplant patients who want blood tests that can detect early signs of organ rejection. Medicare patients can’t get them, even as the tests are categorized as “medically necessary” by private insurance.

MolDX, a program run by Medicare contractor Palmetto GBA to make coverage decisions on molecular lab tests, issued guidance last year saying that such blood tests can’t be used for regular monitoring for organ rejection, only ordered in lieu of biopsies. It was a blow to transplant patients, who lost access to a noninvasive option that raises the likelihood of maintaining the health of their new organs.

Here’s the double standard: Palmetto GBA’s parent company, BlueCross BlueShield of South Carolina, recently said its private kidney patients will continue to have access to the same tests, according to a recent report by the American Association of Kidney Patients. In a recent medical policy update, BlueCross BlueShield of South Carolina has affirmed that molecular blood testing is “medically necessary” once a month for four months after a kidney transplant and then every three months afterward. No connection to biopsy required. Coverage was also extended to heart transplant patients.

That’s a sensible policy for a treatment option that makes a material difference in transplant outcomes and quality of life for patients. The question is why Medicare isn’t covering the same tests. For the record, Palmetto GBA’s directors include top executives from BlueCross BlueShield of South Carolina, including CEO Mike Mizeur and board chairman David Pankau.

The Centers for Medicare and Medicaid Services has denied any change in coverage, arguing that the guidance was issued in response to “improper billing and overutilization of these tests.” That’s another way of saying they were frequently ordered by doctors, who considered them a useful tool. MolDX has made no effort to adjust its policy. How does it explain the differing guidance for its parent company’s private insurance patients?