LCD Reference Article Response To Comments Article

Response to Comments: Prostate Cancer Detection with IsoPSA®

A59242

Expand All | Collapse All
Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A59242
Original ICD-9 Article ID
Not Applicable
Article Title
Response to Comments: Prostate Cancer Detection with IsoPSA®
Article Type
Response to Comments
Original Effective Date
10/06/2022
Revision Effective Date
N/A
Revision Ending Date
N/A
Retirement Date
N/A

CPT codes, descriptions, and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution, or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

N/A

Article Guidance

Article Text

This article contains the responses to comments submitted regarding IsoPSA® Prostate Cancer Detection test based on revised draft policy DL39284 presented at open meeting on 6/21/22.

Response To Comments

Number Comment Response
1

Broaden the range of patient total PSA values covered to 4-100 ng/mL

Cleveland DX requests to broaden the range of patient total PSA values covered to 4-100 ng/mL. As a ratio metric test, IsoPSA diagnostic performance is unaffected by absolute PSA value. IsoPSA has been proven to be effective across a broad range of total PSA values (4 ng/mL – 100 ng/mL), exhibiting consistent performance in patients across the breadth of PSA values seen in routine clinical practice. A new study by Klein et al (2022) was submitted and they referred to Lotan 2021, Stovasky 2019, Klein 2017 as well.

Klein et al (2022) is a prospective, multi-center validation study of the diagnostic performance of IsoPSA for Prostate Cancer (PcA). For IsoPSA, diagnostic performance was evaluated only in patients within the intended use population of the test of men age > 50 years and PSA > 4ng/mL. In this study sub-group analysis was conducted for PSA levels of 4-10 ng/mL and PSA >10 ng/mL. The authors report that IsoPSA maintained statical accuracy across a broad range of elevated total PSA ranging from 4-100 ng/mL in 888 subjects. 24% (217/888) of study subjects had a PSA >10 ng/mL. 54 subjects (14.8%) of the sub-set with PSA >10-25 ng/mL had a negative biopsy while 44 (21.3%) has low grade PCa and 96 (30.4%) had high-grade PCa (Table 1). The NCCN Guidelines algorithm considers biomarkers in this population to potential aid in evaluation as well.

 

However, only 23 subjects or 2.5% (23/888) had total PSA values >25 ng/mL with 20 of those predictably having high grade PCa (Gleason >7). Specificity (SP) and NPV (negative predictive value) decreased modestly in the group with total PSA >10 ng/mL and further breakdown of the small sub-set with PSA> 25 (n=23) was not reported in the study (Table 6). In this population higher SP and NPV are desired as the risk of malignancy is increase with PSA >25 ng/mL making need for additional evaluation and/or biopsy more likely. Further evaluation of the IsoPSA test at the higher PSA levels with a larger number of patients to ensure the test is appropriately triaging those these high-risk individuals is necessary and malignancy is not missed. Additionally, long-term follow-up with an understanding of rate of missed cancers in this population and necessary follow-up has not been determined. Therefore, the range was broadened to upper limit of ≤25 ng/mL. 

2

Expand range of patient biopsy status to include those with previous negative biopsy

Cleveland DX requests to expand the range of patient-specific biopsy status to include also those patients having had previous negative biopsy. IsoPSA has been proven to perform consistently among patients with prior negative biopsy results as well as among those prior to their initial biopsies.

In Klein et al. (2022) 40% (354/888) of study subjects had a prior negative biopsy. In the group with at least 1 prior negative biopsy, IsoPSA yielded a moderate AUC (0.82), a modest specificity = 46% and good NPV=95% for High-Grade PCa on subsequent biopsy in 202 subjects with prior negative biopsies.

This demonstrates diagnostic performance of IsoPSA was consistent regardless of prior biopsy status.

In the study protocol exclusion criteria included recent prostate biopsy (≤ 30 days prior to study participation), however in Scovell et al. (2021) in a real-world population 44% (324/734) had prior negative biopsies without this exclusion criteria.

This is a diagnostically challenging group and the high NPV in this population is clinical useful to aid in management therefore the policy will be expanded to allow prior negative biopsy. This is consistent with NCCN Guidelines for evaluation of patients with at least one negative biopsy where the panel recommends multiparametric MRI and allows biomarkers if clinically indicated. Therefore the limitation to initial biopsy was removed.

3

Remove restrictions regarding patients with symptomatic BPH (benign prostate condition) and, accordingly, the use of medications such as 5α reductase (5-ARIs) and alpha blockers

Cleveland DX requests remove restrictions regarding patients with symptomatic BPH, a benign prostate condition which often precipitates the use of medications such as 5-ARIs and/or alpha blockers. Because structural changes in cancer-related PSA are unaffected by drugs that lower PSA level, medications including 5ARIs and alpha blockers do not interfere with the diagnostic performance of IsoPSA. They reference Klein et al. (20220 as well as other published studies on IsoPSA patients with symptomatic BPH taking 5_ARIs (Klein 2017, Stovsky 2019, Scovell 2021).

New Evidence was submitted in Klein et al. (2022) reported that IsoPSA is unaffected by the use of 5a-reductase inhibitors or alpha blockers consistent with the other referenced studies. The same author, Klein (2017), stated “because IsoPSA measures PSA structure rather than concentration, men on 5-ARIs, which are known to affect PSA concentration, were not excluded.” Therefore, this limitation will be removed. 

4

IsoPSA definition – B&C article

Cleveland DX believes that the code initially proposed by CGS (89240) is inappropriate as it does not properly describe IsoPSA. IsoPSA is a lab procedure and not a pathology procedure. Note that 89240 is listed under the physician fee schedule, whereas IsoPSA should be listed under the lab fee schedule. IsoPSA is not a tissue- or fluid-based based pathology evaluation, rather it is a blood-based immunoassay with proprietary algorithm. recommends instead using the unlisted MAAA code 81599.

CGS has reviewed CPT 81599 and agree this is the most accurate code until a specific code is issued and B&C has been modified.

5

Cleveland DX - minor typographical errors

These have been corrected.

N/A

Coding Information

Bill Type Codes

Code Description

Please accept the License to see the codes.

N/A

Revenue Codes

Code Description

Please accept the License to see the codes.

N/A

CPT/HCPCS Codes

Please accept the License to see the codes.

N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

Bill Type Codes

Code Description

Please accept the License to see the codes.

N/A

Revenue Codes

Code Description

Please accept the License to see the codes.

N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L39284 - Prostate Cancer Detection with IsoPSA®
Related National Coverage Documents
N/A
SAD Process URL 1
N/A
SAD Process URL 2
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
09/30/2022 10/06/2022 - N/A Currently in Effect You are here

Keywords

N/A