Disease

There are three main types of hematologic malignancies: lymphomas, leukemias, and myelomas. Lymphoma begins in lymph cells of the immune system, which originate in the bone marrow and collect in lymph nodes and other tissues. Leukemia is caused by the overproduction of abnormal white blood cells in the bone marrow, which leads to a decrease in the production of red blood cells and plasma cells. The most common forms of leukemia are acute lymphoblastic leukemia, chronic lymphocytic leukemia, acute myeloid leukemia, and chronic myeloid leukemia. Multiple myeloma (MM), also called plasma myeloma, is a malignancy of plasma cells in the bone marrow. The present policy will address B-cell acute lymphoblastic leukemia and MM.

Treatment

Treatment depends on the type of malignancy and may include surgery, radiotherapy, chemotherapy, targeted therapy, plasmapheresis, biologic therapy, or hematopoietic cell transplant. Treatment of acute leukemias can lead to complete remission. MM and the chronic leukemias are treatable but generally incurable. Patients are typically followed by complete blood count and morphologic assessment of bone marrow. Complete hematologic response is defined as a bone marrow blast (immature cells) composition of less than 5% and hematologic recovery (normal neutrophil and platelet count) without the need for red blood cell transfusions.

Measurable Residual Disease

Relapse is believed to be due to residual clonal cells that remain following "complete response” after induction therapy but are below the limits of detection using conventional morphologic assessment. Residual clonal cells that can be detected in the bone marrow are referred to asMRD, also known as minimal residual disease. MRD assessment is typically performed by flow cytometry or polymerase chain reaction (PCR) with primers for common variants. Flow cytometry evaluates blasts based on the expression of characteristic antigens, while PCR assesses specific chimeric fusion gene transcripts, gene variants, and overexpressed genes. PCR is sensitive for specific targets, but clonal evolution may occur between diagnosis, treatment, remission, and relapse that can affect the detection of MRD. Next-generation sequencing (NGS) has 10- to 100-fold greater sensitivity for detecting clonal cells, depending on the amount of DNA in the sample (see Table 1) and does not require patient-specific primers. For both PCR and NGS a baseline sample at the time of high disease load is needed to identify tumor-specific sequences. MRD with NGS is frequently used as a surrogate measure of treatment efficacy in drug development.

It is proposed that by using a highly sensitive and sequential MRD surveillance strategy, one could expect better outcomes when therapy is guided by molecular markers rather than hematologic relapse. However, some patients may have hematologic relapse despite no MRD, while others do not relapse despite residual mutation-bearing cells. Age-related clonal hematopoiesis, characterized by somatic variants in leukemia-associated genes with no associated hematologic disease, further complicates the assessment of MRD. One available test (ClonoSEQ) uses both PCR and NGS to detect clonal DNA in blood and bone marrow. ClonoSEQ Clonality (ID) PCR assessment is performed when there is a high disease load (eg, initial diagnosis or relapse) to identify dominant or “trackable” sequences associated with the malignant clone. NGS is then used to monitor the presence and level of the associated sequences in follow-up samples. As shown in Table 1, NGS can detect clonal cells with greater sensitivity than either flow cytometry or PCR, although next-generation flow techniques have reached a detection limit of one in 10^-5 cells, which is equal to PCR and approaches the limit of detection of NGS (see Table 1).

Table 1. Sensitivity of Methods for Detecting Minimal Residual Disease

Technique	Sensitivity	Detection limit of blasts per 100,000 Nucleated Cells
Microscopy (complete response)		50,000
Multiparameter flow cytometry	10-4	10
Next-generation flow cytometry	10-5	1.0
Polymerase chain reaction	10-5	1.0
Quantitative next-generation sequencing	10-5	1.0
Next-generation sequencing	10-6	0.1

Regulatory Status

The ClonoSEQ® Minimal Residual Disease Test is offered by Adaptive Biotechnologies. ClonoSEQ® was previously marketed as ClonoSIGHT™ (Sequenta), which was acquired by Adaptive Biotechnologies in 2015. ClonoSIGHT™ was a commercialized version of the LymphoSIGHT platform by Sequenta for clinical use in MRD detection in lymphoid cancers. In September 2018, ClonoSEQ received marketing clearance from the Food and Drug Administration through the de novo classification process to detect MRD in patients with acute lymphoblastic leukemia or MM.

Related Policies

• Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome (Policy #048 in the Treatment Section)
• Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia (Policy #038 in the Treatment Section)

2. Next-generation sequencing to detect measurable residual disease (MRD) at a threshold of less than 10^-4 in members with acute lymphoblastic leukemia is considered investigational.

3. Next-generation sequencing to detect MRD at a threshold of 10^-4 as an alternative test in members with multiple myeloma is considered medically necessary.

4. Next-generation sequencing to detect measurable residual disease (MRD) at a threshold of less than 10^-4 in members with multiple myeloma is considered investigational.

5. Next-generation sequencing to detect MRD is considered investigational in all other situations.


Medicare Coverage:
Per the Decision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer (CAG-00450N), effective March 16, 2018, and NCD 90.2, NGS is covered if the test is performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician and when all of the following criteria are met:

· The Individual has either recurrent, relapsed, refractory, metastatic, or advanced stages III or IV cancer; and
· The Individual has either not been previously tested using the same NGS test for the same primary diagnosis of cancer or repeat testing using the same NGS test only when a new primary cancer diagnosis is made by the treating physician; and
· The Individual has decided to seek further cancer treatment (e.g., therapeutic chemotherapy).

· Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and,
· FDA-approved or -cleared indication for use in that individual’s cancer; and,
· Results provided to the treating physician for management of the individuals’s treatment using a report template to specify treatment options.

· ovarian or breast cancer; and
· a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer; and
· a risk factor for germline (inherited) breast or ovarian cancer; and
· was not been previously tested with the same germline test using NGS for the same germline genetic content.

· Food and Drug Administration (FDA) approval or clearance; and
· results provided to the treating physician for management of the individual using a report template to specify treatment options

· any cancer diagnosis; and
· a clinical indication for germline (inherited) testing of hereditary cancers; and
· a risk factor for germline (inherited) cancer; and
· has not been previously tested with the same germline test using NGS for the same germline genetic content.

Evidence reviews assess whether a medical test is clinically useful. A useful test provides information to make a clinical management decision that improves the net health outcome. That is, the balance of benefits and harms is better when the test is used to manage the condition than when another test or no test is used to manage the condition.

The first step in assessing a medical test is to formulate the clinical context and purpose of the test. The test must be technically reliable, clinically valid, and clinically useful for that purpose. Evidence reviews assess the evidence on whether a test is clinically valid and clinically useful. Technical reliability is outside the scope of these reviews, and credible information on technical reliability is available from other sources.

Next-Generation Sequencing to Detect Measurable Residual Disease in B-Cell Acute Lymphoblastic Leukemia

Clinical Context and Test Purpose

ALL is the most common cancer diagnosed in children; it represents nearly 25% of cancers in children younger than 15 years and 20% of acute leukemias in adults. Remission of disease is now typically achieved with pediatric chemotherapy regimens in 98% of children with ALL, with up to 85% long-term survival rates. The prognosis after the first relapse is related to the length of the original remission. For example, the leukemia-free survival rate is 40% to 50% for children whose first remission was longer than 3 years compared with 10% to 15% for those who relapse less than 3 years after treatment. Between 60% and 80% of adults with ALL can be expected to achieve a complete response (CR) after induction chemotherapy; however, only 35% to 40% can be expected to survive 2 years. “Poor prognosis” genetic abnormalities such as the Philadelphia chromosome (translocation of chromosomes 9 and 22) are seen in 25% to 30% of adult ALL but infrequently in childhood ALL. Other adverse prognostic factors in adult ALL include age greater than 35 years, poor performance status, male sex, and leukocytosis count of greater than 30000/μL (B-cell lineage) or greater than 100000/μL (T-cell lineage) at presentation.

Induction therapy aims to reduce the leukemic cell population below the cytological detection limit (about 10¹⁰cells or 1 malignant cell for every 20 to 100 normal cells), but it is believed that remaining leukemic cells that are below the level of clinical and conventional morphologic detection lead to relapse if no further treatment were given.^1,2, Consolidation and intensification therapy is intended to eradicate this residual disease. The type of post-remission therapy (chemotherapy or autologous or allogeneic hematopoietic cell transplantation [HCT]) depends on the expected rate of relapse and patient characteristics such as age and comorbidities. Bone marrow is examined every three to six months for a minimum of two years to determine clinical relapse. If a patient is in CR for seven to eight years they are considered cured. Most children and up to one-half of adults will have prolonged disease-free survival, but up to 20 percent of adults will have a resistant disease, and a majority of adults and some children will eventually relapse and die of leukemia.^3,4,

Measurable, or minimal residual disease (MRD) is used to assess the subclinical residual disease. Patients with detectable MRD have an increased risk of relapse, but the absolute risk varies depending on the timing of MRD evaluation, the sensitivity of the method used, and baseline characteristics of the patient and tumor. ^3,4, In addition, not all patients with MRD positivity will relapse clinically because some cells with abnormal markers may lack the ability to create disease. Other patients will relapse despite no detectable disease as a result of malignant progenitor cells that lack the initially identified markers. MRD is most commonly measured with polymerase chain reaction (PCR) and flow cytometry (FC).

MRD assays are routinely used in the clinical care of children and increasingly in adults with ALL, although the choice of tests may depend on how the results will impact patient care.^3,4, FC may be preferred if there are plans to escalate care because results are rapidly available and the likelihood of relapse with this less sensitive test is high. PCR may be preferred to identify patients with a low risk of relapse when a reduction in treatment intensity is being considered. Some clinicians use more than one technique to minimize false-negative results, or at multiple time points to assess disease trajectory, and ongoing trials are evaluating whether children who demonstrate a rapid clearance of tumor cells during induction therapy may be candidates for less intensive therapy. In adults who have a high rate of relapse, MRD is being studied to identify patients who require intensified treatment. One drug (blinatumomab) has received approval from the U.S. Food and Drug Administration to treat MRD positive B-cell precursor ALL with MRD positivity of 0.1% or greater (10^-3).^5,

Next-generation sequencing (NGS) is a newer technique that is commercially available (eg, ClonoSEQ). NGS is more sensitive than other methods and can detect up to 1 leukemic cell in 1000000 cells if there is sufficient DNA in the sample (see Table 1), but other performance characteristics are not well established.

Test Purpose

The main use of measurement of MRD with NGS is to risk-stratify and inform treatment management.

Measures of MRD can be used used to assess whether a patient has failed to fully respond to treatment or is progressing after responding to treatment. If a patient meets the criteria for nonresponse or for relapse, the clinical decision generally would be to provide additional therapy prior to transplant. The analytic framework for the use of MRD for ALL, based on guidelines from the National Comprehensive Cancer Network^6,, is shown in Figure 1.

Figure 1. Analytic Framework for the use of MRD to Inform Treatment Management.

The question addressed in this policy is: Does the use of NGS for MRD at different thresholds (eg, 10^-4 or <10^-4) improve the net health outcome in patients with B cell-ALL (B-ALL)?

The following PICOs were used to select literature to inform this review.

Patients

The relevant population of interest are patients who have received induction therapy for B-ALL (see Figure 1). Patients who achieve a clinical CR following induction therapy would be assessed for MRD to determine whether additional therapy might be recommended prior to HCT. Patients who have relapsed or refractory diseases would be assessed for the Philadelphia chromosome and if negative may undergo assessment for MRD.

Interventions

The test being considered is MRD assessment by NGS (eg, ClonoSEQ). This test is proposed as an adjunct to clinical assessment and an alternative toFC and PCR. NGS utilizes locus-specific primers for immunoglobulin gene rearrangements in IGH-VDJH, IGHDJH, or IGK. This technique does not require the use of patient-specific primers, but baseline bone marrow samples are required in order to identify the dominant clonotype. MRD positivity or negativity is reported at all thresholds (eg positive at 10^-4 but negative at 10^-5). The sensitivity of this technique can reach up to 10⁻⁶ depending on the quantity of DNA available from the bone marrow sample. This policy will evaluate outcomes for NGS at different thresholds.

Comparators

The following tests are currently being used to inform treatment decisions for those with B-ALL: FC (sensitivity of 10^-4) and PCR (sensitivity of 10^-5). Meta-analysis of 39 studies (13637 patients) that evaluated survival outcomes found that MRD negativity with either FC or PCR was associated with a better long-term outcome.^7, Ten-year event-free survival with MRD negativity was 77% in children and 64% in adults compared to 32% and 21%, respectively, in patients who were MRD positive. For reference, the event-free survival hazard ratio (HR) for MRD negativity/positivity with FC or PCR was 0.23 (95% Bayesian credible interval 0.18-0.28) for pediatric patients and 0.28 (95% Bayesian credible interval, 0.24-0.33) for adults.

Outcomes

The general outcomes of interest are remission and relapse in the short-term and survival at a longer follow-up.

Beneficial outcomes of a true-positive test result (presence of clinically significant residual disease) would be the administration of an effective treatment leading to a reduction in relapse and improvement in overall survival (OS). The beneficial outcome of a true-negative test (absence of clinically significant disease) is the avoidance of unnecessary treatment and reduction of adverse events.

Harmful outcomes of a false-positive test arean unnecessary treatment for ALL resulting in treatment-related harms. Harmful outcomes of a false-negative test are a reduction in necessary treatment that would delay treatment, with a potential impact in progression-free survival (PFS) and OS.

Direct harms of the test are repeated bone marrow biopsy, although bone marrow samples are also needed for FC. Harms of repeated bone marrow biopsy may include tenderness or pain, bleeding or bruising, and swelling.

Relapse of B-ALL may be measured in two years. Changes in survival from B-ALL would be observable at a minimum of five years.

Study Selection Criteria

For the evaluation of theclinical validity of the ClonoSEQ test, studies that met the following eligibility criteria were considered:

• Included a suitable reference standard (PFS or OS)
• Evaluated outcomes at different levels of MRD or compared NGS to FC

Technically Reliable

Assessment of technical reliability focuses on specific tests and operators and requires a review of unpublished and often proprietary information. Review of specific tests, operators, and unpublished data are outside the scope of this policy and alternative sources exist. This policy focuses on clinical validity and clinical utility.

Clinically Valid

A test must detect the presence or absence of a condition, the risk of developing a condition in the future, or treatment response (beneficial or adverse).

Tables 2, 3, and 4 describe studies that have evaluated prognosis based on MRD levels detected by FC and NGS. Overall, higher levels of MRD are associated with a worse prognosis. In a study by Wood et al (2018), there was high concordance between FC and NGS at a threshold of 10^-4 in pediatric B-ALL (data are shown graphically in the publication).^8, A subset of these results was submitted to the Food and Drug Administration in support of their de novo clearance. OS in pediatric patients with MRD positivity was significantly lower than in pediatric patients who were MRD negative at this threshold. At an MRD threshold of 10^-4, NGS identified 55 patients as MRD-positive who were MRD-negative by FC, while 17 patients were MRD-positive by FC but MRD-negative by NGS (see Table 3). Patients who were FC negative/NGS positive had outcomes that were midway between patients who were concordant as MRD positive or MRD negative for both tests.

Notably, higher levels of sensitivity were associated with a decrease in clinical specificity, with a larger fraction of MRD-positive patients with relatively good outcome (data not shown in the publication). With MRD negativity set at a threshold of 10^-6, OS was 100% in the standard-risk group and 95.1% in the high-risk group (see Table 4), but at this threshold, there was not a statistically significant difference in OS between the MRD positive and MRD negative patients for either group. The maximal HR for NGS was obtained at 10^-4, which is the sensitivity of FC. A smaller study by Pulsipher et al (2015) compared NGS at 10^-6 with FC assessed before and after HCT in pediatric patients with ALL.^9, NGS was more successful at predicting the relapse probability and OS compared to FC. The major limitations of these studies are shown in Tables 5 and 6. A limitation in Wood et al (2018) is that samples were only available at the end of induction, so the results only apply to the end of induction. In addition, the data on sensitivity and specificity at other thresholds were not reported, although the study did assess the threshold with the greatest HR, which was calculated to be 10^-4 (the same as FC). Both studies were conducted in pediatric ALL patients, and results may not apply fully to adults or be applicable to other periods in the treatment course.

No studies were identified that evaluated the use of NGS to detect MRD in adult ALL.

Table 2. Characteristics of Prognostic Studies Assessing NGS for MRD

Study	Study Population	Designa	Reference Standard	Threshold for PIT	FU, y	Test Version
Wood et al (2018)8,	619 paired bone marrow samples from pediatric B-ALL patients before and after induction chemotherapy in COG trials	Retrospective from banked samples with comparison of FC and NGS	Event-free survival and overall survival	FC at 10-4 NGS at 10-4 and 10-5	5	ImmunoSEQ
Pulsipher et al (2015)9,	Before (n=41) and after HCT (n=57) marrow samples from pediatric ALL patients in COG trials	Retrospective from banked samples with comparison of FC and NGS	Time to relapse following HCT	FC at 10-4 NGS at 10-6		ImmunoSEQ

ALL: acute lymphoblastic leukemia; COG: Children's Oncology Group; FC: flow cytometry; FU: follow-up; HCT: hematopoietic cell transplantation; MRD: measurable residual disease; NGS: next-generation sequencing; PIT: positive index test.

Table 3. Concordance Between FC and NGS at a Threshold of 10^-4 from Wood et al (2018)^8,

		Flow Cytometry
		+	-	Total
NGS	+	87	55	142
	-	17	409	426
	Total	104	464	568

FC: flow cytometry; NGS: next-generation sequencing.

Table 4. Results of Prognostic Studies Assessing NGS for MRD

Study	N	MRD Threshold	Results
			Relapse Probability at 2 Years, %	5-Year EFS, % (SD)	OS % (SD)	Hazard Ratio
Wood et al (2018)8,	282 Standard Risk	EOI NGS negative <10-6 (n=56)		98.1 (2)	100 (0)	Maximal at 10-4
	297 High Risk	EOI NGS negative <10-6 (n=89)		92.7 (4)	95.1 (3)
Pulsipher et al (2015)9,	41	Pre-HCT FC negative	16
		Pre-HCT NGS negative	0
		Pre-HCT FC positive	46
		Pre-HCT NGS positive	53

EFS: event-free survival; EOI: end of induction; FC: flow cytometry; HCT: hematopoieticcell transplantation; MRD: measurable residual disease; NGS: next-generation sequencing; OS: overall survival; : positive predictive value; TTP: time to progression.

Limitations in relevance and design and conduct are shown in Tables 4 and 5.

Table 5. Relevance Limitations

Study	Populationa	Interventionb	Comparatorc	Outcomesd	Duration of FUe
Wood et al (2018)8,	4. Results are specific to pediatric B-ALL. Stored samples were available only at the end of induction	3. Used ImmunoSEQ rather than ClonoSEQ
Pulsipher et al (2015)9,	4. Results are specific to pediatric ALL.	3. Used ImmunoSEQ rather than ClonoSEQ

The study limitations stated in this table are those notable in the current review; this is not a comprehensive limitations assessment.
ALL: acute lymphoblastic leukemia; FU: follow-up.

^a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.

^b Intervention key: 1. Classification thresholds not defined; 2. Version used unclear; 3. Not intervention of interest.

^c Comparator key: 1. Classification thresholds not defined; 2. Not compared to credible reference standard; 3. Not compared to other tests in use for same purpose.

^d Outcomes key: 1. Study does not directly assess a key health outcome; 2. Evidence chain or decision model not explicated; 3. Key clinical validity outcomes not reported (sensitivity, specificity, and predictive values); 4. Reclassification of diagnostic or risk categories not reported; 5. Adverse events of the test not described (excluding minor discomforts and inconvenience of venipuncture or noninvasive tests).

^e Follow-Up key: 1. Follow-up duration not sufficient with respect tonatural history of disease (true-positives, true-negatives, false-positives, false-negatives cannot be determined).

Table 6. Study Design and Conduct Limitations

Study	Selectiona	Blindingb	Delivery of Testc	Selective Reportingd	Data Completenesse	Statisticalf
Wood et al (2018)8,	2. Selection based on availability of tissue samples from prior studies			2. NGS at 10-4 was not prespecified. The lack of specificity with other thresholds was mentioned
Pulsipher et al (2015)9,	2. Selection based on availability of tissue samples from prior studies	1. Blinding was not described

NGS: next-generation sequencing.

The study limitations stated in this table are those notable in the current review; this is not a comprehensive limitations assessment.

^a Selection key: 1. Selection not described; 2. Selection not random or consecutive (ie, convenience).

^bBlinding key: 1. Not blinded to results of reference or other comparator tests.

^cTest Delivery key: 1. Timing of delivery of index or reference test not described; 2. Timing of index and comparator tests not same; 3. Procedure for interpreting tests not described; 4. Expertise of evaluators not described.

^d Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.

^e Data Completeness key: 1. Inadequate description of indeterminate and missing samples; 2. High number of samples excluded; 3. High loss to follow-up or missing data.

^f Statistical key: 1. Confidence intervals and/or p values not reported; 2. Comparison with other tests not reported.

Section Summary: Clinical Validity

Evidence on the clinical validity of NGS to risk-stratify patients includes two retrospective studies in pediatric patients with ALL who had participated in earlier trials by the Children's Oncology Group. The largest study was conducted in stored samples from before and after induction therapy, and MRD negativity was one of several factors that were used to risk-stratify patients. Comparison with FC showed comparable results when the same threshold (10^-4) was used for both NGS and FC, and OS in pediatric patients with MRD positivity was significantly lower than in pediatric patients who were MRD negative. However, NGS at the limit of detection (10^-6 or 1 leukemic cell in 1000000 normal cells) was found to have lower specificity. Thus, in one study of over 600 pediatric patients with B-ALL undergoing induction, risk stratification based on NGS and FC were comparable at a threshold of 10^-4, but NGS had more false-positives with lower thresholds.

Clinically Useful

A test is clinically useful if the use of the results informs management decisions that improve the net health outcome of care. The net health outcome can be improved if patients receive correct therapy, or more effective therapy, or avoid unnecessary therapy, or avoid unnecessary testing.

Direct Evidence

Direct evidence of clinical utility is provided by studies that have compared health outcomes for patients managed with and without the test. Because these are intervention studies, the preferred evidence would be from randomized controlled trials (RCTs). No trials were identified that compared outcomes when treatment was guided by NGS.

Chain of Evidence

Indirect evidence on clinical utility rests on clinical validity. If the evidence is insufficient to demonstrate test performance, no inferences can be made about clinical utility.

There is sufficient evidence on test performance when results of the NGS are reported at 10^-4, which is comparable to other established methods of measuring MRD such as FC. However, performance characteristics at lower thresholds are uncertain, and there is some evidence that false-positives may be increased with a more sensitive test. Therefore, a chain of evidence cannot be constructed regarding the clinical utility of measurement of MRD at less than 10^-4 in patients with ALL.

Section Summary: NGS to Detect MRD in ALL

Evidence is sufficient to support the clinical utility of using NGS to measure MRD when patient management is based on test results at a sensitivity of 10^-4. Evidence is insufficient to evaluate benefits and harms when treatment decisions are made based on NGS results at thresholds lower than 10^-4. Few studies have been performed to assess whether the identification of 1 in 1000000 cells identifies clinically significant residual disease, and false-positives may be increased resulting in harm from overtreatment. Further study is needed to clarify which threshold of NGS should be considered when risk stratifying patients and whether treatment decisions based on the more sensitive assay improves the net health outcome.

Next-Generation Sequencing to Detect Measurable Residual Disease in Multiple Myeloma

Clinical Context and Test Purpose

MM represents approximately 17% of all hematologic cancers, largely occurring in patients over 60. It is characterized by the proliferation of plasma cells in the bone marrow producing a monoclonal immunoglobulin. The clonal plasma cells frequently result in extensive skeletal destruction with osteolytic lesions, osteopenia, and/or pathologic fractures; additional complications can include hypercalcemia, renal insufficiency, anemia, and infections.^10,

MM is treatable but is typically incurable, with treatment reserved for patients with the symptomatic disease (usually progressive). Without effective therapy, symptomatic patients die within a median of six months. Asymptomatic patients are observed because there is little evidence that early treatment of asymptomatic MM prolongs survival compared with therapy delivered at the time of symptoms or end-organ damage. In some patients, an asymptomatic but more advanced premalignant stage is referred to as smoldering MM. Patients with smoldering MM may remain stable for prolonged periods, with an overall risk of disease progression from smoldering to symptomatic MM of 10% per year for the first five years, approximately 3% per year for the next five years, and 1% for the next ten years.

Prognosis and treatment for MM depend on risk stratification based on underlying genetic variants, age, performance status, comorbidities, stage, and response to therapy. Patients are assessed to determine eligibility for HCT because HCT has been shown to prolong both event-free and OS compared with chemotherapy alone. The response to treatment is usually determined by a morphologic evaluation and visual quantitation of the percentage of plasma cells in the bone marrow. Most patients with MM will have an initial response to treatment, but will ultimately progress with serial relapse, and will be treated with most available agents at some point during their disease course. Other patients will not respond to initial treatment (refractory disease).

Response to treatment is categorized into clinical response, MRD response, and imaging response. A complete (clinical) response is defined by the International Myeloma Working Group and the National Comprehensive Cancer Network as shown in Table 7.^11,12, MRD response is defined as a CR plus the absence of clonal plasma cells by next-generation flow (NGF) or NGS at a minimum sensitivity of 1 in 10⁵ nucleated cells in bone marrow, and there is a category of “imaging plus MRD-negative” in which patients are determined to have a CR, be MRD negative in the bone marrow, and have also achieved PET/CT-negativity. "Sustained MRD negativity” is achieved when both imaging plus MRD are negative in assessments that are a minimum of one year apart. It is not known whether patients with sustained MRD negative status can be considered cured. MRD measured by NGS is currently used as a surrogate outcome measure in clinical trials, and there are ongoing trials to test the effectiveness of using NGS-MRD to guide therapy.^13,

Table 7. Definitions of Complete Response and Measurable Residual Disease Criteria from the International Myeloma Working Group^11,

Standard Response Criteria
Complete response	"Negative immunofixation on the serum and urine and disappearance of any soft tissue plasmacytomas and <5% plasma cells in bone marrow aspirates"
MRD Response Criteria (requires a complete response)
Sequencing MRD-negative	Absence of clonal plasma cells with a minimum sensitivity of 1 in 10⁵ nucleated cells
Imaging plus MRD-negative	MRD negativity by NGF or NGS plus imaging criteria

MRD: minimal residual disease; NGF: next-generation flow; NGS: next-generation sequencing

Test Purpose

The main use of measurement of MRD is to inform treatment management.

Measures of MRD can be used used to assess whether a patient has responded to treatment, has not fully responded to treatment, or has progressed. The analytic framework for the use of MRD for MM, based on guidelines from the NationalComprehensive Cancer Network ^12,, is shown in Figure 2. If a patient meets the criteria for CR and MRD, the patient could proceed to maintenance therapy or observation. If, however, a patient meets the criteria for nonresponse or for progression, the clinical decision would be to proceed to the next line of therapy for the previously treated disease. The National Comprehensive Cancer Network guidelines recommend guiding treatment based on multiparameter FC (threshold of 10-4), with NGF or NGS used for prognosis at a threshold of 10-5 or 10-6. NGF is not widely performed in the U.S.

Figure 2. Analytic Framework for the use of MRD to Inform Treatment Management in MM.

Clinical pathways subsequent to treatment failure or relapse incorporate an accumulation of clinical trial evidence and are codified in clinical guidelines.

The question addressed in this policy is: Is the net health outcome improved when treatment is guided by MRD measured by NGS in patients with MM?

The following PICOs were used to select literature to inform this review.

Patients

The relevant population of interest are patients who are undergoing or have undergone treatment for MM.

Interventions

The test being considered is MRD assessment by NGS (eg, ClonoSEQ). NGS utilizes locus-specific primers for immunoglobulin gene rearrangements, which are rearranged in myeloma patients. Baseline bone marrow samples at the time of high disease load are required in order to identify the dominant clonotype. With the ClonoSEQ test, dominant ("clonogenic") sequences can be identified in ~92% of MM patients, while dominant sequences cannot be identified in the other ~ 8% of patients.

Comparators

Evaluation for disease progression in MM typically includes serum protein electrophoresis, serum immunofixation, 24-hour urine protein electrophoresis, urine immunofixation, and serum-free light chain, hemoglobin, serum calcium, and creatinine. A bone marrow aspirate and biopsy is not always needed but can clarify disease status and determine if a change in the cytogenetic characteristics has occurred. MRD detection by NGS would be an adjunct to clinical measures of progression and an alternative to FC, which has a sensitivity of 10^-4.

Outcomes

The general outcomes of interest are a clinical progression in the short term and survival at a longer follow-up.

Beneficial outcomes of a true-positive test result (detection of clinically significant disease) would be intensification or continuation of an effective treatment leading to longer PFS. The beneficial outcome of a true-negative test (absence of clinically significant residual disease) is the avoidance of unnecessary treatment and reduction of adverse events.

Harmful outcomes of a false-positive test include an increase or continuation of unnecessary treatment resulting in treatment-related harm. Harmful outcomes of a false-negative test include a reduction in necessary treatment that would delay treatment, with a potential impact in disease progression.

Direct harms of the test are repeated bone marrow biopsy. Harms of repeated bone marrow biopsy may include tenderness or pain, bleeding or bruising, and swelling.

Utility of MRD to guide treatment of MM may be measured in months for progression of the disease, with survival measured in years.

Study Selection Criteria

For the evaluation of theclinical validity of the ClonoSEQ test, studies that met the following eligibility criteria were considered:

• Included a suitable reference standard (PFS or OS)
• Evaluated outcomes at different levels of MRD

Technically Reliable

Assessment of technical reliability focuses on specific tests and operators and requires a review of unpublished and often proprietary information. Review of specific tests, operators, and unpublished data are outside the scope of this policy and alternative sources exist. This policy focuses on the clinical validity and clinical utility.

Clinical Validity

A test must detect the presence or absence of a condition, the risk of developing a condition in the future, or treatment response (beneficial or adverse).

Two published retrospective studies were identified that evaluated the association between MRD by NGS and disease progression in patients with MM (see Table 8). Both studies assessed MRD levels from patients who had participated in earlier MM treatment trials (the GEM myeloma trials and the IFM 2009 trial). Martinez-Lopez et al (2014) assessed the time to progression (TTP) stratified by MRD at levels from 10^-3 to < 0^-5 and found that the TTP was associated with the level of MRD.^14, Specifically, median progression was 27 months for patients with MRD >10^-3, 48 months for patients with MRD between 10^-3 and 10^-5, and 80 months for patients with MRD <10^-5 , giving a HR of 3.97 for higher levels of MRD (p< 0.001, see Table 9). In the subgroup of patients with CR, TTP was 131 months in MRD negative patients and 35 months in MRD positive patients (HR of 2.87, p<0.001).

When compared to multiparameter FC, 82 of 99 results (83%) were concordant (see Table 10). NGS identified an additional 12 patients with MRD that were MRD-negative by FC, while 5 patients were found to be flow MRD+/NGS MRD- (see Table 10). One of five flow+/NGS- patients progressed. Patients who were NGS+/flow- had an intermediate TTP (50 months) compared to NGS-negative patients (TTP not reached; P<0.0001).

In Perrot et al (2018), a threshold of 10^-6 was used to evaluate the association between MRD andPFS, finding that the dichotomous division into MRD positive and MRD negative (no detectable MRD at the limit of detection) was highly predictive of PFS with anHR for MRD negative/MRD positive of 0.19 (p<0.001).^15, The median PFS was 29 months in patients who were positive for MRD and was not reached among patients with no detectable MRD.

The major limitations of these studies are described in Tables 11 and 12. The report by Perrot et al (2018) was described as exploratory analysis, and in the study by Martinez-Lopez et al (2014), it does not appear that analysis by the level of MRD was pre-specified. In addition, the sample size in the study by Martinez-Lopez et al (2014) was limited by the availability of stored tissue from the earlier clinical studies. Perrot et al (2018) had a larger sample from the IFM 2009 trial but did not separately assess the subgroup of patients who had CR. Although Perrot et al (2018) also had a high number of cases that were not available for assessment, the publication supplement included a sensitivity analysis to examine the effect of missing data. The analysis was conducted using multiple imputations to impute missing MRD values. The results from the sensitivity analyses were reported to be similar to the primary results.

Similar results were obtained in the retrospective studies submitted for the Food and Drug Administration de novo application using a threshold of 10^-5 to determine MRD negativity. ^16, In the 75 patients who had a CR in thephase 3 DFCI 10-106 study, continuous levels of MRD were marginally associated with PFS (p=0.064). Analysis from all participants in the phase 3 ALCYONE trial found that MRD negativity was associated with longer PFS (patients without a CR were considered MRD positive), but results were not reported separately for patients with CR.

Table 8. Characteristics of Studies Assessing NGS for MRD

Study	Study Population	Design	Reference Standard	Threshold	Test Version
Martinez-Lopez et al (2014)14,	Patients with available bone marrow samples from GEM myeloma trialsa	Retrospective	TTP	MRD at 10-3 and 10-5	LymphoSIGHT
Perrot et al (2018)15,	Patients with myeloma enrolled in the IFM 2009 clinical trialb	Retrospective	PFS and OS	MRD at 10-6	ClonoSEQ

MRD: measurable residual disease; NGS: next-generation sequencing; OS: overall survival; PFS: progression-free survival; TTP: time to progression.

^a GEM (Grupo Español deMieloma) myeloma treatment trials

^bIFM 2009 was phase 3 trial from the Intergroupe Francophone du Myelome, conducted between 2010 and 2012, which evaluated the role of autologous cell transplantation in patients with newly diagnosed myeloma.

Table 9. Results of Prognostic Studies Assessing NGS for MRD

Study	N	MRD Threshold	TTP, mo (95% CI)
Martinez-Lopez et al (2014)14,	133	>10-3	27
		10-3 to 10-5	48
		<10-5	80
Hazard Ratio for Time to Progression			3.97
p-Value			<0.001
Subset of patients with CR	26	<10-5	131 (51-154)
Subset of patients with CR	36	>10-5	35 (30-41)
Hazard Ratio for Time to Progression			2.87
p-Value			<0.001
Perrot et al (2018)15,	509	10-6	MRD negative/MRD positive
Hazard Ratio for Progression Free Survival (95% CI)			0.19 (0.13 to 0.26)
p-Value			<0.001

CI: confidence interval; CR: complete response; MRD: measurable residual disease; NGS: next-generation sequencing; TTP: time to progression.

Table 10. Concordance Between NGS and FC in Study by Martinez-Lopez (2014)

		Flow Cytometry
		+	-	Total
NGS	+	60	12	72
	-	5	22	27
	Total	65	34	99

FC: flow cytometry; NGS: next-generation sequencing.

Table 11. Relevance Limitations

Study	Populationa	Interventionb	Comparatorc	Outcomesd	Duration of FUe
Martinez-Lopez et al (2014)14,				3. No data were reported using a threshold of 10-6 since most of the samples had less input cells than is needed for this level of sensitivity
Perrot et al (2018)15,	4. The study included patients from the IFM 2009 trial who had at least a very good partial response but did not report separately on patients with a complete response

The study limitations stated in this table are those notable in the current review; this is not a comprehensive limitations assessment.
FU: follow-up.

^a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.

^b Intervention key: 1. Classification thresholds not defined; 2. Version used unclear; 3. Not intervention of interest.

^c Comparator key: 1. Classification thresholds not defined; 2. Not compared to credible reference standard; 3. Not compared to other tests in use for same purpose.

^d Outcomes key: 1. Study does not directly assess a key health outcome; 2. Evidence chain or decision model not explicated; 3. Key clinical validity outcomes not reported (sensitivity, specificity, and predictive values); 4. Reclassification of diagnostic or risk categories not reported; 5. Adverse events of the test not described (excluding minor discomforts and inconvenience of venipuncture or noninvasive tests).

^e Follow-Up key: 1. Follow-up duration not sufficient with respect to natural history of disease (true-positives, true-negatives, false-positives, false-negatives cannot be determined).

Table 12. Study Design and Conduct Limitations

Study	Selectiona	Blindingb	Delivery of Testc	Selective Reportingd	Data Completenesse	Statisticalf
Martinez-Lopez et al (2014)14,	2. Selection based on availability of tissue samples from prior studies	1. Blinding not described				1. The analysis by level of MRD does not appear to be prespecified.
Perrot et al (2018)15,	2. Selection based on availability of tissue samples in the original study	1. Blinding not described				1. Post-hoc exploratory analysis, not adjusted for multiple comparisons

MRD: measurable residual disease

The study limitations stated in this table are those notable in the current review; this is not a comprehensive limitations assessment.

^a Selection key: 1. Selection not described; 2. Selection not random or consecutive (ie, convenience).

^bBlinding key: 1. Not blinded to results of reference or other comparator tests.

^cTest Delivery key: 1. Timing of delivery of index or reference test not described; 2. Timing of index and comparator tests not same; 3. Procedure for interpreting tests not described; 4. Expertise of evaluators not described.

^d Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.

^e Data Completeness key: 1. Inadequate description of indeterminate and missing samples; 2. High number of samples excluded; 3. High loss to follow-up or missing data.

^f Statistical key: 1. Confidence intervals and/or p values not reported; 2. Comparison with other tests not reported.

Section Summary: Clinical Validity

The evidence on NGS for detection of MRD includes two published retrospective studies and additional retrospective studies from the Summary of Safety and Effectiveness of the de novo application for ClonoSEQ in patients with MM. These studies evaluated the association between the level of MRD detected by NGS in the bone marrow and the TTP from the completed phase 3 trials. All of the studies demonstrated an association between the level of MRD and PFS with longer TTP in patients who exhibit MRD negativity below 10^-5 or 10^-6 compared to patients who have detectable residual disease. There was also high concordance between NGS and FC. Patients who were discordant for the two tests had outcomes that were intermediate between patients who were positive for both tests and those who were negative for both tests.

Clinically Useful

A test is clinically useful if the use of the results informs management decisions that improve the net health outcome of care. The net health outcome can be improved if patients receive correct therapy, or more effective therapy, or avoid unnecessary therapy, or avoid unnecessary testing.

Direct Evidence

Direct evidence of clinical utility is provided by studies that have compared health outcomes for patients managed with and without the test. Because these are intervention studies, the preferred evidence would be fromRCTs.

No RCTs assessing the clinical utility of MRD by NGS to guide therapywere identified.

Chain of Evidence

Indirect evidence on clinical utility rests on clinical validity. High concordance has been shown between NGS and FC at a threshold of 10-4, indicating that NGS may be considered an alternative to FC at this threshold.

The retrospective studies are insufficient to demonstrate clinical validity at thresholds lower than 10-4. Levels of MRD are associated with average prognosis, but performance characteristics are unknown at the level of sensitivity that is provided by NGS. A potential benefit of NGS assessment of MRD would be if patients were able to forgo maintenance therapy if there was no detectable MRD. However, it is unknown whether therapy can be safely eliminated based on this test.

Section Summary: Clinically Useful

In an exploratory analysis of the largest study to date, the median PFS was 29 months in patients who were positive for MRD and was not reached among patients with no detectable clones, suggesting that assessment of MRD might have utility in guiding therapy. Although there is high concordance between FC and NGS at a threshold of 10-4, performance characteristics, such as the rate of false-positives, at more sensitive thresholds are unknown. About one-quarter of MRD negative patients progressed within 36 months in these trials, raising questions about whether NGS could be used to guide therapy. It is unknown whether progression is due to very low levels of residual disease or to new clonal rearrangements in MM. Direct evidence from RCTs is needed to evaluate whether patient outcomes are improved by changes in postinduction care (eg, continuing or discontinuing therapy, avoiding unnecessary adverse events) following NGS assessment of residual disease. Several trials that will test the effectiveness of MRD to guide therapy in MM are ongoing.

Summary of Evidence

For individuals with B-ALL who are being monitored for residual disease following treatment who receive NGS for MRD at a threshold of 10^-4, the evidence includes a retrospective comparison of data from two earlier trials by the Children's Oncology Group. The relevant outcomes are OS, disease-specific survival, test validity, change in disease status, quality of life (QOL), and treatment-related morbidity. Comparison of NGS and the established standard ofFC showed good concordance when the same threshold (10^-4) was used for both NGS and FC. OS in pediatric patients with MRD positivity was significantly lower than in pediatric patients who were MRD negative at this threshold. The relatively small subset of patients who were discordant for FC and NGS results had outcomes that were midway between patients who were concordant as MRD positive or MRD negative for both tests. As the vast majority of patients had concordant results for NGS and FC at a threshold of 10^-4, NGS can be considered an alternative to FC for monitoring MRD in patients with B-ALL. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with B-ALL who are being monitored for residual disease following treatment who receive NGS for MRD at a threshold of less than 10^-4, the evidence includes retrospective analysis of prognosis from the earlier Children's Oncology Group trials. The relevant outcomes are OS, disease-specific survival, test validity, change in disease status, QOL, and treatment-related morbidity. NGS can be more sensitive than FC to detect the presence of residual leukemic cells, but specificity may be decreased at the more sensitive thresholds resulting in potential harm from overtreatment. Further study is needed to clarify whether MRD at levels lower than 1 in 10000 cells represents clinically significant disease and if the more sensitive test can be used to risk-stratify patients with B-ALL. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals with MM who have achieved a CR following treatment who receive NGS for MRD at a threshold of 10^-4, the evidence includes a retrospective comparison of NGS and FC data from MM treatment trials. The relevant outcomes are OS, disease-specific survival, test validity, change in disease status, QOL, and treatment-related morbidity. Comparison of NGS and the established standard ofFC at 10^-4 show good concordance. PFS in patients with MRD positivity is significantly shorter than in patients who are MRD negative at this threshold. The relatively small subset of patients who were discordant for FC and NGS results had outcomes that were, on average, midway between patients who were concordant as MRD positive or MRD negative for both tests. As the vast majority of patients had concordant results for NGS and FC at a threshold of 10^-4, NGS can be considered an alternative to FC for monitoring MRD in patients with MM. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with MM who have achieved a CR following treatment who receive NGS for MRD at a threshold of less than 10^-4, the evidence includes retrospective studies on prognosis. The relevant outcomes are OS, disease-specific survival, test validity, change in disease status, QOL, and treatment-related morbidity. There is some evidence that MRD may be a prognostic marker, but there is insufficient evidence on the number of false-positives in patients with CR at the more sensitive threshold provided by NGS to guide therapy. A chain of evidence regarding management changes based on the assessment of MRD with NGS to detect 1 malignant clonal sequence out of 1000000 cells cannot be completed. Direct evidence from RCTs is needed to evaluate whether patient outcomes are improved by changes in postinduction care (eg, continuing or discontinuing therapy, avoiding unnecessary adverse events) following NGS assessment of residual disease at a threshold lower than 10^-4. Several trials that will test the effectiveness of NGS to guide therapy in MM are ongoing. The evidence is insufficient to determine the effects of the technology on health outcomes.

SUPPLEMENTAL INFORMATION

Practice Guidelines and Position Statements

International Myeloma Working Group

The International Myeloma Working Groupdeveloped consensus criteria for response and minimal residual disease assessment in multiple myeloma (see Table 13).^11,

Table 13 IMWG Criteria

Standard Response Criteria
Complete response	"Negative immunofixation on the serum and urine and disappearance of any soft tissue plasmacytomas and <5% plasma cells in bone marrow aspirates"
Stringent complete response	"Complete response as defined below plus normal FLC ratio** and absence of clonal cells in bone marrow biopsy by immunohistochemistry (κ/λ ratio ≤4:1 or ≥1:2 for κ and λ patients, respectively, after counting ≥100 plasma cells)"
MRD Response Criteria (requires a complete response)
Sequencing MRD-negative	Absence of clonal plasma cells by NGS using the LymphoSIGHT platform (or validated equivalent ) with a minimum sensitivity of 1 in 10⁵ nucleated cells
Imaging plus MRD-negative	MRD negativity by NGF or NGS plus imaging criteria
Sustained MRD-negative	MRD negativity by NGF or NGS, and by imaging, at a minimum of 1 year apart.

FLC: free light chain;IMWG: International Myeloma Working Group; MRD: minimal residual disease; NGF: next-generation flow; NGS: next-generation sequencing.

The National Comprehensive Cancer Network

The National Comprehensive Cancer Network has published guidelines of relevance to this review (see Table 14).

Table 14. Recommendations on Assessing Measurable Residual Disease

Guideline	Version	Recommendation
Acute lymphoblastic leukemia6,	2.2019	Risk stratification after treatment induction by MRD positivity. MRD in ALL refers to the presence of leukemic cells below the threshold of detection by conventional morphologic methods. The most frequently employed methods for MRD assessment are FC, RQ-PCR, and NGS. The concordance rate between these methods is generally high.
Multiple myeloma12,	2.2020	Bone marrow aspirate with multiparameter flow cytometry is to be used as clinically indicated following treatment. MRD tests should be initiated only at the time of suspected CR. and can be assessed for prognosis after a shared decision with the patient.

ALL: acute lymphoblastic leukemia, CR: complete response; FC: flow cytometry; MRD: measurable residual disease; NGS: next-generation sequencing; RQ-PCR: real-time quantitative polymerase chain reaction.

U.S. Preventive Services Task Force Recommendations

Not applicable.

Ongoing and Unpublished Clinical Trials

Some currently ongoing and unpublished trials that might influence this review are listed in Table 15.

Table 15. Summary of Key Trials

NCT No.	Trial Name	Planned Enrollment	Completion Date
Ongoing
NCT03509961	A Phase II Pilot Trial to Estimate Survival After a Non-total Body Irradiation (TBI) Based Conditioning Regimen in Patients Diagnosed With Acute Lymphoblastic Leukemia (ALL) Who Are Pre-allogeneic Hematopoietic Cell Transplantation (HCT) Next-generation-sequence (NGS) Minimal Residual Disease (MRD) Negative (ENRAD)	95	Apr 2022
NCT03224507	Monoclonal Antibody-Based Sequential Therapy for Deep Remission in Multiple Myeloma - MASTER Trial	82	Apr 2023
NCT03914625	A Phase 3 Trial Investigating Blinatumomab ( NSC# 765986) in Combination With Chemotherapy in Patients With Newly Diagnosed Standard Risk or Down Syndrome B-Lymphoblastic Leukemia (B-ALL) and the Treatment of Patients With Localized B-Lymphoblastic Lymphoma (B-LLy)	6720	Jun 2027

NCT: national clinical trial.]
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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

___________________________________________________________________________________________________________________________

Index:
Next-Generation Sequencing for the Assessment of Measurable Residual Disease
ClonoSEQ® Minimal Residual Disease Test (Adaptive Biotechnologies)
ClonoSIGHT™ (Sequenta)
LymphoSIGHT (Sequenta)
Minimal Residual Disease, Next-Generation Sequencing for
Measurable Residual Disease, Next-Generation Sequencing for

References:
1. Larson RA. Post-remission therapy for Philadelphia chromosome-negative acute lymphoblastic leukemia in adults. UpToDate. https://www.uptodate.com/contents/post-remission-therapy-for-philadelphia-chromosome-negative-acute-lymphoblastic-leukemia-in-adults. Accessed September 6, 2019.

2. Larson RA. Treatment of relapsed or refractory acute lymphoblastic leukemia in adults. UpToDate. https://www.uptodate.com/contents/treatment-of-relapsed-or-refractory-acute-lymphoblastic-leukemia-in-adults. Accessed September 6, 2019.

3. Stock W and Estrov Z Clinical use of measurable residual disease detection in acute lymphoblastic leukemia. UpToDate. https://www.uptodate.com/contents/clinical-use-of-measurable-residual-disease-detection-in-acute-lymphoblastic-leukemia Accessed September 6, 2019.

4. Stock W and Estrov Z Detection of measurable residual disease in acute lymphoblastic leukemia. UpToDate. https://www.uptodate.com/contents/detection-of-measurable-residual-disease-in-acute-lymphoblastic-leukemia. Accessed September 6, 2019.

5. U.S. Food and Drug Administration. Prescribing information for BLINCYTO. 2018; https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/125557s013lbl.pdf. Accessed October 5, 2018.

6. National Comprehensive Care Network. NCCN Clinical Practice Guidelines in Oncology: Acute Lymphoblastic Leukemia. Version 2.2019. https://www.nccn.org/professionals/physician_gls/pdf/all.pdf. Accessed September 4, 2019.

7. Berry DA, Zhou S, Higley H, et al. Association of Minimal Residual Disease With Clinical Outcome in Pediatric and Adult Acute Lymphoblastic Leukemia: A Meta-analysis. JAMA Oncol, 2017 May 12;3(7). PMID 28494052

8. Wood B, Wu D, Crossley B, et al. Measurable residual disease detection by high-throughput sequencing improves risk stratification for pediatric B-ALL. Blood. Mar 22 2018;131(12):1350-1359. PMID 29284596

9. Pulsipher MA, Carlson C, Langholz B, et al. IgH-V(D)J NGS-MRD measurement pre- and early post- allotransplant defines very low- and very high-risk ALL patients. Blood. May 28 2015;125(22):3501-3508. PMID 25862561

10. Rajkumar SV. Multiple myeloma: Clinical features, laboratory manifestations, and diagnosis, UpToDate. https://www.uptodate.com/contents/multiple-myeloma-clinical-features-laboratory-manifestations-and-diagnosis. Accessed September 6, 2019.

11. Kumar S, Paiva B, Anderson KC, et al. International Myeloma Working Group consensus criteria for response and minimal residual disease assessment in multiple myeloma. Lancet Oncol., 2016 Aug 12;17(8). PMID 27511158

12. National Comprehensive Care Network. NCCN Clinical Practice Guidelines in Oncology: Multiple Myeloma. Version 3.2019. https://www.nccn.org/professionals/physician_gls/pdf/myeloma.pdf. Accessed August 29, 2019.

13. Bal S, Weaver A, Cornell RF, et al. Challenges and opportunities in the assessment of measurable residual disease in multiple myeloma. Br. J. Haematol., 2019 Aug 1. PMID 31364160

14. Martinez-Lopez J, Lahuerta JJ, Pepin F, et al. Prognostic value of deep sequencing method for minimal residual disease detection in multiple myeloma. Blood. May 15 2014;123(20):3073-3079. PMID 24646471

15. Perrot A, Lauwers-Cances V, Corre J, et al. Minimal residual disease negativity using deep sequencing is a major prognostic factor in multiple myeloma. Blood, 2018 Sep 27;132(23). PMID 30249784

16. U.S. Food and Drug Administration. Evaluation of automatic class II designation for clonoSEQ Assay; Decision summary https://www.accessdata.fda.gov/cdrh_docs/reviews/DEN170080.pdf. Accessed September 6, 2019.

Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

81479
81599