APOE Test not covered by Medicare?

HutchGS · November 15

Our neurologist ordered an APOE blood test prior to prescribing Kisunla. When we went for the test we were told it would not be covered by Medicare or Tricare and would cost $700. Is this what others have experienced?

And is the APOE test actually required? We've done the PET scan. Of course, we'll find the money if the APOE test is essential in minimizing risk. Just curious what others experience has been.

harshedbuzz · November 15

I believe the APOE testing is standard for safety reasons.

https://pennmemorycenter.org/kisunla-donanemab/

SDianeL · November 16

found this online: Yes,

Medicare Part B covers the APOE gene testwhen it is ordered by a treating physician to help determine a patient's eligibility and risk for specific FDA-approved amyloid-lowering infusion therapies for early Alzheimer's disease, such as Leqembi (lecanemab).

SDianeL · November 16

and this:

Consult with your doctor: Have your doctor determine if the ApoE test is medically necessary for your specific condition.
Contact TRICARE: Before the test, contact your TRICARE contractor to confirm coverage based on your specific situation. You can also ask about pre-authorization requirements.

SDianeL · November 16

I believe the test is medically necessary before infusion to determine possible side effects like brain swelling or brain bleeding. The purpose of an APOE test before an infusion is

to assess the risk of a serious side effect called Amyloid-Related Imaging Abnormalities (ARIA)(also known as brain swelling or microbleeds) when starting certain Alzheimer's disease treatments

, like lecanemab. Testing identifies if a patient carries the APOE ε4 allele, as

APOE ε4 homozygotes have a much higher risk of developing ARIA

compared to heterozygotes and noncarriers. This information helps guide the decision to proceed with treatment and informs the discussion about risks versus benefits with the patient.

harshedbuzz · November 16

@HutchGS

I wonder if the ordering physician improperly or incompletely coded the order? That's a common scenario for insurance denials.

APOE Test not covered by Medicare?

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