The Migrating Gapfill Price of Decipher Prostate Test in 2020 Gapfill Process

81542 was a new code for Decipher Prostate test.  CMS reviewed the code in CY2019 and decided it should be gapfilled in CY2020.

The initial MACs gapfill in early June 2020 was $2431, driven by MOLDX, whereas I believe the company most likely wanted parity with Oncotype Prostate and Prolaris, and parity with those tests had been the status quo when they all had unlisted codes.

The final MAC gapfill in October 2020 was $3159, reflecting an uplift in price from MolDx.

However, the "final final" fee schedule for Cy2021, released in December, reflected a higher price of $3873.  This would usually reflect an appeal by the stakeholder, to CMS staff, AFTER the "final" MAC gapfill was finished.   This $3873 level also represented a final parity between the adjacent codes 81541 Prolaris and 81542 Decipher, and I think that Oncotype Prostate is the same.

A shareable file summarizing the open public data on each successive fee schedule,  is in the cloud here.

click to enlarge