Coverage Indications, Limitations, and/or Medical Necessity
This policy provides limited-coverage for molecular phenotyping of erythrocyte antigens performed on the HEA BeadChip™ (Immucor, Warren, NJ), a single nucleotide polymorphisms (SNP)-based microarray test. This high-throughput molecular assay received FDA PMA approval in May, 2014 and is the only IVD- approved molecular test to characterize human red blood cell (RBC) antigens.
Many clinically significant antigens are encoded by alleles defined by SNPs. This assay identifies 35 antigens and 3 phenotypic variants across 11 blood groups (Rh, Kell, Duffy, Kidd, MNS, Lutheran, Dombrock, Landsteiner-Wiener, Diego, Colton and Scianna). Genomic DNA targets isolated from whole blood are amplified and fluorescent signals are interpreted by online software as specific alleles and probable antigen phenotype. This test does not evaluate patient antibody status.
For more than ten years, RBC genotyping has been applied mainly to mass screen donors in blood centers. American Rare Donor Program, a consortium of the American Red Cross and American Association of Blood Banks (AABB) accredited immunohematology reference laboratories have used molecular genotype information for several years to identify antigen negative blood units from donor for patients with antibodies. Blood centers also use molecular technology to genotype donors for certain antigens (eg, Dombrock) that are hard to ascertain because of antisera unavailability or weak potency.
Hemagglutination is the most common serologic method of determining a RBC phenotype. In this technique, the patient’s RBCs are tested with antisera specific for the antigens of interest. However, hemagglutination testing cannot be used if a patient has a positive direct antiglobuin test (DAT), or if direct agglutination typing sera is not available for the antigen. In addition, serologic phenotyping is invalid in the transfused patient who may have persistent donor RBCs in circulation. Because molecular genotyping is not subject to the limitations of serologic testing, it has become a useful tool in large hospital transfusion services.
As early as 1999, Legler et al demonstrated disparate molecular Rh phenotyping in 7 of 27 patients compared to serologic typing.
Soon afterwards, Reid and others demonstrated that DNA from blood samples could be used to genotype patients who had recently been transfused.
Castilho et al confirmed the unreliability of serologic testing when they showed that 6 of 40 molecular genotypes differed from serologic phenotypes in multiply transfused sickle cell anemia (SCA) patients, and in 9 of 10 alloimmunized thalassemic patients.
A number of investigators have replicated these findings, most notably Bakanay et al when they demonstrated genotypic and phenotypic discrepancies in 19 or 37 multi-transfused patients in multiple alleles. The discrepancies aided in the selection of antigen-matched blood products and improved RBC survival, ultimately improving patient care.
A recent case report by Wagner emphasizes the usefulness of molecular testing over serologic testing in chronically transfused patients.
In a prospective observational study, Klapper et al. used the HEA BeadChip™ to provide extended human erythrocyte antigen (xHEA) phenotyped donor units and recipient patient samples. XHEA-typed units were assigned to pending transfusion requests using a web-based inventory management system to simulate blood order processing at four hospital transfusion services. The fraction of requests filled (FF) in 3 of 4 sites was > 95% when matching for ABO, D and known alloantibodies, with a FF of > 90% when additional matching for C, c, E, e, and K antigens. The most challenging requests came from the fourth site where the FF was 62 and 51% respectively, even with a limited donor pool.
In a prospective observational study by Da Costa et al, 21 of 35 sickle cell anemia (SCA) patients had discrepancies or mismatches, mainly in the Rh, Duffy, Jk and MNS blood groups, between the genotype profile and the serologically-matched blood unit for multiple antigens.
These authors report that their genotype-matching program resulted in elevated hemoglobin levels, increased time between transfusions and prevented the development of new alloantibodies.
Two recently published papers have shown the feasibility of routinely applying molecular blood banking techniques in a hospital transfusion service. Routine RBC testing has been implemented in a large tertiary care hospital in Los Angeles, CA to maximize efficient use of blood units. Patients with warm or cold reacting autoantibodies, patients with SCA and patients with antibodies that could not be identified were molecularly genotyped and received molecularly matched blood from the hospital’s genotyped donor inventory.
At a large hospital in Cleveland, OH, pre-transfusion molecular typing is performed on chronically transfused patients, patients with autoantibodies, multiple antibodies, when no antigen specific antibody is available for testing and to solve laboratory discrepancies. They authors note that the major benefit of molecular typing is its application for patients who cannot be typed by serology due to an unsuitable sample. Valid results can be obtained even when they have been transfused within a few days of testing or have been massively transfused. Samples selected for molecular testing were based on an algorithm.
Medicare will cover pretransfusion molecular testing using the HEA BeadChip™ assay for the following categories of patients:
- Long term, frequent transfusions anticipated to prevent the development of alloantibodies (e.g. sickle cell anemia, thalassemia or other reason);
- Autoantibodies or other serologic reactivity that impedes the exclusion of clinically significant alloantibodies (e.g. autoimmune hemolytic anemia, warm autoantibodies, patient recently transfused with a positive DAT, high-titer low avidity antibodies, other reactivity of no apparent cause);
- Suspected antibody against an antigen for which typing sera is not available; and
- Laboratory discrepancies on serologic typing (e.g. rare Rh D antigen variants)
Medicare does not expect molecular testing to be performed on patients undergoing surgical procedures such as bypass or other cardiac procedures, hip or knee replacements or revisions, or patients with alloantibodies identifiable by serologic testing that are not expected to require long term, frequent transfusions.
The medical necessity for molecular RBC phenotying must be documented in the patient’s medical record.