In Summer 2024, when Exact Sciences asked for a 1.25X price for its Cologuard version 2 test, I had the sense that type of CMS decision was unlikely. I looked back through 4 or 5 years of final CMS CLFS crosswalks, and multiples were very rarely. One test with 4 slides got priced at 0.5X a test with 8 slides. Nobody in years, had gotten 1.2X or 1.4X because they were sort of more resources. One CMS answer would be to ask the applicant with that request to prove with math while an increment of, say, 1.5X was write and better than 1.4X or 1.6X.
CMS has put this in writing:
In an effort to maintain consistency across the entirety of recommendations, in most cases we support and recommend to crosswalk the new codes without multipliers.
Fall 2018, final determinations of CW for 2019.
Separately, CMS has referred to economies or efficiencies of scale, as in pricing new code 87494, proposed crosswalks, September 2025. CMS writes at item 37:
CMS agrees with the minority Panel recommendation because 87494 describes use of a multiplex platform. CMS believes there are efficiencies to this new assay such that simply adding the two separate assays together does not represent the resources required.
Since 87801 allows for multiple analyses, CMS believes this is an appropriate crosswalk.
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