- Madison, Wis.-based Exact Sciences, which provides the non-invasive test for colorectal cancer Cologuard, is suing Humana for refusing to pay for thousands of screenings totaling $800,000 in claims, Louisville Business First reports.
- Exact Sciences complains 4,664 Humana enrollees in 45 states have undergone the test but Humana hasn't been paying since at least October 2014, saying it doesn't cover Cologuard.
- Further upsetting Exact Sciences, Humana began trying to prevent further enrollee use of the test by notifying Kentucky providers it isn't covered, prompting a cease and desist notice from Exact Sciences.
The issue is not just payment for those claims already submitted; Exact Sciences is questioning Humana's legal basis for choosing not to cover the test.
The test provider notes many states mandate insurer coverage of colorectal cancer screenings, including Kentucky, where the colorectal cancer rate is significantly higher than the national average and a state statute stipulates insurers must cover "all colorectal cancer examinations and laboratory tests specified in current American Cancer Society guidelines," which have included Cologuard for two years.
Exact Sciences further argues for Humana to cover the service in all states, even where there is no mandate, and says the insurer has caused Exact Sciences "to sustain substantial damages."
Louisville Business First notes the test is approved by the FDA and is covered by the CMS and several other commercial insurers. The publication says Humana declined to comment on the case.