Surely not the end of Pacific Edge is it?
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Surely not the end of Pacific Edge is it?
Nah, not the end. Pacific Edge will flog off Cxbladder, get Dave back (having probably sold his shares now and owning the biggest deck in Dunnie?) to start all over again with Colorectal cancer and drum up some more enthusiasm and cash...The Scientists will happilly carry on with what they love doing. When that fails, they'll get onto the Melanoma thing and finally wrap up the deal in Spain.
So essentially this was a lie? https://www.directbroking.co.nz/Dire...spx?id=5400495
So I asked PEB back in 2021 what "medically necessary" meant. This is their reply
July LCD by CMS: The link you have provided is an earlier version of the ‘proposed
LCD’ which was in circulation for consultation. The final published LCD is L35396 and
the exclusion language relating to Cxbladder you refer to was removed following
submissions from Pacific Edge and other parties such that now the only requirement for
reimbursement by CMS is the use of valid CPT codes and the statement of medical
necessity. Medical necessity is determined by the referring physician and does not
require that Cxbladder is used instead of cystoscopy, since in most cases Cxbladder is
used in addition to cystoscopy in the US. Provided these criteria are met (which they are
for all CMS patients) Pacific Edge is receiving 100% (full) reimbursement for claims
within 40 days of claim submission. As we noted in the newsletter and at the half year,
CMS related tests accounted for a significant proportion (~67%) of our commercial test
throughput in the US for the first half of FY21 – this is quite different from the ‘very few’
you suggest.
My interpretation of that response is that they'd leave it to you to find out how, why and when the referring physician determines medical necessity. My argument at the time was that it would be unlikely a physician could comfortably make a determination outside the governing AUA or NCCN guidelines and so there would not be many situations where the tests were so.
This is why I suspected the refunds made in 2022 and 2023 were likely as a result of later audit by CMS.