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- Flawed Special Stains Policy Finally Revised After Years of Persevering Advocacy by the CAP
In response to direct advocacy by the CAP, Medicare Administrative Contractors (MACs) Palmetto GBA and Wisconsin Physicians Service updated their Local Coverage Determinations (LCDs) for Special Histochemical Stains and Immunohistochemical Stains (‘special stains’). The policy revisions are the result of extensive advocacy by the CAP and its members over the past ten years, and a direct response to the CAP’s formal reconsideration request initiated in December 2021.
The revised LCDs, which become effective July 14, 2024, expand coverage for Lynch Syndrome tumor screening for microsatellite instability (MSI) / DNA mismatch repair by removing the age limitation, and coverage for IHC for breast pathology to include Ki-67 in a specific population of breast cancer patients. Additional modifications to the LCD coverage criteria allow for greater flexibility for testing in areas like breast, lung, and prostate pathology. Overall, the LCD is less prescriptive and offers clearer actionable guidance for pathologists and other physicians seeking to be compliant in reporting a single service. Further, the updates help to restore physician judgment, as supported by medical evidence.
The special stains LCD covers eight different subspecialties within pathology and is shared by four MACs – Cigna Government Services (CGS), Noridian, Palmetto and Wisconsin Physician Services (WPS). In addition to Palmetto and WPS, the CAP anticipates CGS and Noridian will also adopt the new revisions to their special stains policies.
The revised LCD contains some new documentation requirements for when additional testing is necessary and CAP members should familiarize themselves with the new requirements.