DESCRIPTION
Ovarian cancer is the second most common type of female reproductive cancer and is the leading cause of death from gynecological cancer with a 5-year survival rate below 30% if the cancer is caught in stage III or higher. Adult women presenting with an adnexal mass have an estimated 68% likelihood of having a benign lesion, 6% have borderline tumors, 22% invasive lesions, and 3% metastatic disease. The need for proper triage and specialty care is warranted to improve survival and health outcomes.
A variety of proteomic biomarkers have been studied in association with ovarian cancer. Of particular interest are tests that develop a risk score based on the results of multiple analytes. They have been investigated for use in women with adnexal masses of unknown origin based on routine clinical and radiological evaluations. The scores can be used to estimate the probability of an underlying malignant process and may be useful in determining the pre-operative plan of care.
Several of these tests (e.g., Overa®, OVA1® and ROMA®) have been designated as Class II devices by the FDA. They are quantitative serum tests that employ specific algorithms to ascribe the risk score.
POLICY
Proteomics-based testing (e.g., Overa®, OVA1®, and ROMA®) for all uses, including but not limited to the following, is considered investigational:
preoperative evaluation of adnexal masses to assess for malignancy
screening for ovarian cancer
selecting individuals for surgery for an adnexal mass
evaluation of individuals with clinical or radiologic evidence of malignancy
evaluation of individuals with nonspecific signs or symptoms suggesting possible malignancy
postoperative testing and monitoring to assess surgical outcome and/or to detect recurrent malignant disease following treatment
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g., statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
ADDITIONAL INFORMATION
The evidence for use of proteomics-based testing (e.g., Overa®, OVA1® test or ROMA® test) is insufficient to determine the effects of the technology on health outcomes.
SOURCES
American College of Obstetricians and Gynecologists. (2016). Evaluation and management of adnexal masses. Practice Bulletin 174. Retrieved August 7, 2017 from The American College of Obstetricians and Gynecologists.
BlueCross BlueShield Association. Evidence Positioning System. (1:2023). Multimarker serum testing related to ovarian cancer (2.04.62). Retrieved March 10, 2023 from https://www.evidencepositioningsystem.com/. (30 articles and/or guidelines reviewed)
Coleman, R. L., Herzog, T. J., Chan, D. W., Munroe, D. G., Pappas, T. C., Smith, A., et al. (2016). Validation of a second-generation multivariate index assay for malignancy risk of adnexal masses. American Journal of Obstetrics & Gynecology, 215 (1), 82.e1-82.e11. (Level 4 evidence)
Dayyani, F., Uhlig, S., Colson, B., Simon, K., Rolny, V., Morgensterm, D., et al. (2016). Diagnostic performance of risk of ovarian malignancy algorithm against CA 125 and HE4 in connection with ovarian cancer: a meta-analysis. International Journal of Gynecologic Cancer, 26 (9), 1586-1593. Abstract retrieved August 7, 2017 from PubMed database.
Dunton, C. J., Hutchcraft, M. L., Bullock, R. G., Northrop, L. E., & Ueland, F. R. (2021). Salvaging detection of early-stage ovarian malignancies when CA125 is not informative. Diagnostics (Basel, Switzerland), 11 (8), 1440. (Level 4 evidence)
Goodrich, S. T., Bristow, R. E., Santoso, J. T., Miller, R. W., Smith, A., Zhang, Z., et al. (2014). The effect of ovarian imaging on the clinical interpretation of a multivariate index assay. American Journal of Obstetrics & Gynecology, 210. (Level 2 evidence)
Grenache, D., Heichman, K., Werner, T., & Vucetic, Z. (2015). Clinical performance of two multi-marker blood tests for predicting malignancy in women with an adnexal mass. Clinica Chimica Acta, 438, 358-363. Abstract retrieved August 7, 2017 from PubMed database.
National Comprehensive Cancer Network. (2022, December). NCCN clinical practice guidelines in oncology (NCCN guidelines®). Ovarian cancer including fallopian tube cancer and primary peritoneal cancer, V.1.2023. Retrieved March 10, 2023 from the National Comprehensive Cancer Network.
Simmons, A., Clarke, C., Badgwell, D., Lu, Z., Sokoll, L., Lu, K., et al. (2016). Validation of a biomarker panel and longitudinal biomarker performance for early detection of cancer. International Journal of Gynecologic Cancer, 26 (6), 1070-1077. (Level 4 evidence)
U.S. Food and Drug Administration. (2009, September). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K081754 (Ova1®). Retrieved September 25, 2012 from http://www.accessdata.fda.gov.
U.S. Food and Drug Administration. (2011, September). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K103358 (ROMA®). Retrieved September 25, 2012 from http://www.accessdata.fda.gov.
U.S. Food and Drug Administration. (2016, March). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K150588 (Overa®). Retrieved August 7, 2017 from http://www.accessdata.fda.gov.
U.S. Preventive Services Task Force. (2018). Screening for ovarian cancer US preventive services task force recommendation statement. Retrieved March 13, 2023 from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/ovarian-cancer-screening.
ORIGINAL EFFECTIVE DATE: 5/14/2011
MOST RECENT REVIEW DATE: 5/11/2023
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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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