Medicare PartB to cover anti-amyloid treatments

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Medicare PartB to cover anti-amyloid treatments

Post by NF52 »

CMS announces plan to ensure availability of new Alzheimer’s drugs

The complete announcement is below.

The short summary: This refers specifically refers to drugs which have received full FDA approval, not just accelerated approval. Currently that includes only Aduhelm (aducanumab) although as the press release notes, full approval for Lekembi (lecanemab) may come as early as July--for very specific groups with MCI/Mild AD, confirmation of PET amyloid, ability to tolerate MRIs and PET scans and comply with biweekly infusions for 96 weeks, with monthly infusions for an indeterminate time after that. Access to a medical setting with the staffing and infrastructure to follow patients closely and report results to a national registry will be needed, and those with a variety of medical, psychiatric or risk factors are recommended for exclusion in a recently published "appropriate use recommendation" document. Donanemab is likely to seek full approval this fall.
Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure announced today how people can get drugs that may slow the progression of Alzheimer’s disease covered by Medicare. If the Food and Drug Administration (FDA) grants traditional approval, then Medicare will cover it in appropriate settings that also support the collection of real-world information to study the usefulness of these drugs for people with Medicare.

“Alzheimer’s disease takes a toll on not just the people suffering from the disease but also on their loved ones and caregivers in a way that almost no other illness does. CMS has always been committed to helping people obtain timely access to innovative treatments that meaningfully improve care and outcomes for this disease,” Brooks-LaSure said. “If the FDA grants traditional approval CMS is prepared to ensure anyone with Medicare Part B who meets the criteria is covered. I’m pleased to make this announcement today as part of CMS’ mission to help improve the lives of Americans we serve. I hope we see more private sector partners in this work making their own announcements soon.”
he FDA’s Peripheral and Central Nervous System Drugs Advisory Committee will discuss the results of a confirmatory trial of the Eisai product Leqembi on June 9, with a potential decision on traditional approval possible within weeks. Broader Medicare coverage would begin on the same day the FDA grants traditional approval. Under CMS’ current coverage policy, if FDA grants traditional approval to other drugs in this class they would also be eligible for broader coverage. Currently two drugs in this class have received accelerated approval from the FDA, but no product has received traditional approval.

Medicare will cover drugs with traditional FDA approval when a physician and clinical team participates in the collection of evidence about how these drugs work in the real world, also known as a registry. Clinicians will be able to submit this evidence through a nationwide, CMS-facilitated portal that will be available when any product gains traditional approval and will collect information via an easy-to-use format. This method, and any others that may follow, will adhere to robust privacy protections in accordance with applicable federal laws and regulations, including HIPAA. Researchers will have access to the information to conduct studies, furthering knowledge of how these drugs can potentially help people. CMS is working with multiple organizations that are getting ready to open their own registries. More information will be released as they come on line.

The approach is consistent with CMS’ National Coverage Determination. To get Medicare coverage people will need to 1) be enrolled in Medicare Part B, 2) be diagnosed with mild cognitive impairment or early dementia caused by Alzheimer’s disease, and 3) have a qualified physician participating in a registry, including the options above, with an appropriate clinical team and follow up care. These criteria are in addition to any label requirements the FDA specifies.

Registries are common tools in clinical settings that have successfully gathered information on patient outcomes for decades. There is strong precedent for using registries to gather more information on a newly-approved treatment. For example, when the FDA granted traditional approval to the transcatheter aortic valve replacement (TAVR), CMS required the clinicians and hospitals to participate in a registry to track outcomes. Information gathered from that registry has since been used to further inform Medicare coverage determinations, and to help people and their clinicians make better decisions about whether TAVR is the best treatment for them.

Other registries for drugs that may slow the progression of Alzheimer’s disease may become available in the coming weeks and months. Information will be available at ... evelopment as studies come on line.
FWIW, I've seen articles predicting that this would bankrupt government or insurance companies here or in Europe. I think that's not realistic for this class of drugs.

In the AHEAD clinical trial (people with amyloid and no MCI or dementia), 75-90% of people seeking to enroll at sites did not end up starting on the trial because they did not have "enough" amyloid, were unable or unwilling to have multiple MRIs and PET scans, or unable to manage biweekly visits, including travel time, with the 90-minute infusion + monitoring, plus time for the on-site pharmacist to fill the order (doses are 10 mg/kg of body weight, weighed each time) and an RN to review the recent medical history, note vital signs (BP and pulse) and set up the infusion IV.

Researchers, including those who designed these trials, believe this is a first-in-class decision for a few drugs that will accelerate development of combined amyloid-tau drugs (already starting in small trials), anti-inflammatory drugs, oral anti-amyloid drugs like ALZ-801, etc.

It's notable that CMS recognizes the value of having a national registry of ALL sites administering these drugs to gain much more understanding of real-world barriers to treatment, benefits, side effects and serious adverse events, including deaths.

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Re: Medicare PartB to cover anti-amyloid treatments

Post by Nevada »

NF52: Thanks for this update! I know at least one Alzheimer's Disease Research Center (ADRC) who is gearing up for the expected requests for fully approved anti-amyloid treatments and all the logistics and resources that will be required to treat folks safely. I have heard that many such centers are already stretched trying to run complex clinical trials such as AHEAD so it will likely be a formidable challenge for them. Nevada
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Re: Medicare PartB to cover anti-amyloid treatments

Post by J11 »

Good one, NF52!

There probably should be an RSS Alzheimer tickertape on forum so that all the big news is streaming 24/7. This one was like some of the other big AD stories in the last year ... I was minding my own business and then bammoo ... KOed by reality.

I was wondering when CMS would enter the conversation.

I thought perhaps they might make a comment on the ADCOM page, though I suppose it makes so much more sense to use your own communication channel. There are surprisingly few comments to date at this FDA url. Everyone said pretty much what one would expect. Only surprise was the Alzheimer's Association comment -- they dropped a phone book length comment.

This is what the Alzheimer's Association had to say about CMS policy in their ADCOM comment:

"V. Alzheimer’s Disease Patients Must Have Access to Safe and Effective Treatments
People living with Alzheimer’s disease should have access to Alzheimer’s therapies
determined to be safe and effective by the FDA. We strongly supported the FDA’s accelerated
approval on January 6, 2023 of Leqembi in patients with early Alzheimer disease and strongly
support the FDA approving Leqembi under traditional approval. However, we are very
concerned that, at the present time, patients have very little access to Leqembi despite receiving
accelerated approval by the FDA, because the Centers for Medicare & Medicaid Services (CMS)
has denied coverage of anti-amyloid mAbs under its Coverage with Evidence Development
(CED) policy, except in the extremely limited context of randomized controlled trials.

We hope that, should the FDA grant Leqembi traditional approval, CMS will revisit this
CED policy such that the therapy will be accessible to all Alzheimer’s disease patients indicated
by the FDA’s prescriber information. If CMS instead insists on requiring further studies of
Leqembi within the Medicare population even after a clinical benefit has been demonstrated in a
representative patient population, this would represent yet a further unprecedented step by CMS
to limit coverage for the on-label use of an FDA-approved drug.

When I read that I was fairly shocked and made particular note of it. CMS was still under the CED framework?
I knew that they were, though it seems so out of step with the general spirit of the current conversation. The CMS really even needed a prod to revisit coverage?

The CMS has added a registry requirement that the Alzheimer's Association has already pushed back against.
I am not entirely sure what the registry would in practice mean, though I can imagine that every fatality will be
discussed in minute detail. This would not necessarily be a bad thing and it could help to rapidly translate clinical learnings into clinical benefits, though it needs to be remembered that upwards of 1% of the patients in the Clarity placebo did not survive the randomized portion of the trial. While the assumption will likely be that any fatality in the registry must in some way be caused by Lecanemab, we clearly know that that is untrue. ... 4/comments

If I had to have played the CMS hand, I think I would have waited until after the ADCOM to announce their Alzheimer's policy. Announcing the week before seems somewhat unexpected, though they must have been under enormous political and social pressure to get on side before the meeting. CMS was so deep into ultra vires that they needed a fast policy reset which the removal of coverage of evidence gave them. It is too bad that they were not able to play a more productive role in the amyloid mab discussion, yet their initial final decision gambit placed them into an unsupportable long term stance. They could have played a facilitating role by pushing for conditionalities such as trials to confirm epsilon genotype treatment benefit and in certain subgroups (that patient groups would have likely supported).

However, their overall understanding of Alzheimer science and politics appeared surprisingly weak, so today's complete capitulation is entirely consistent with their past behavior. Considering how many trillions of dollars is involved in Alzheimer's for governments, health insurance, patient well-being etc. , I am somewhat at a loss that there are not more Alzheimer's analysts around to help out organizations that are just way way out of their depth. Perhaps sort of like accountants or some other profession who could give them a professional opinion without becoming too dragged into the large amount of politics involved ... at least they could get the basic facts correct.

I will be interested to see if any more data disclosures will happen for the ADCOM. For example, would they disclose any more of the open label results or perhaps the APOE specific genotype cognitive results from Clarity?
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