98 Background: In 2018, Medicare released a NGS NCD memo which would facilitate reimbursement for NGS tests for patients (pts) with advanced or metastatic cancer who had not been previously tested using NGS for the same cancer and genetic content. We examined the association between the NCD and: a) NGS utilization trends in commercially-insured and Medicare pts and b) repeat NGS testing. Methods: We conducted a retrospective study of pts with advanced non-small cell lung cancer (aNSCLC), metastatic colorectal cancer (mCRC), metastatic breast cancer (mBC) or advanced melanoma (aM), diagnosed 2011 (2013 for mCRC) through Dec. 2019 using the Flatiron Health EHR-derived de-identified database, comprising data from over 280 (largely community based) cancer clinics (~800 sites of care). Pts were classified as Medicare or Commercially insured based on age and insurance type, and grouped into quarters based on their advanced or metastatic diagnosis date. NGS testing rates per quarter were based on evidence of first NGS test within 60 days from diagnosis. We used an interrupted time series analysis to assess NGS utilization trends pre- and post-NCD policy effective date (March 2018). The frequency of repeat NGS testing was assessed among those pts with only 1 primary cancer. Results: The utilization analysis included 70,290 pts while the repeat NGS testing analysis included 51,385 pts. Across the 4 tumors combined, the use of NGS was < 1% in 2011 (both insurance types) and increased to 41% in commercially-insured pts and 37% in Medicare in 2019. In each tumor, NGS utilization was < 6% in Q1 2014; however, the rate of increase varied by tumor, with aNSCLC increasing to 58% in commercial and 48% in Medicare, while mBC and aM remained < 20% in Q4 2019. Among pts with aNSCLC, mCRC, or mBC, the quarterly rate of increase in NGS testing was higher post-NCD compared to pre-NCD (p < 0.05 for pre-post difference in rate of NGS increase within each cancer type). The difference in trends pre- and post-NCD was not significantly different between commercial and Medicare in any of the tumors (p > 0.05 within each cancer type). Repeat NGS testing increased over time from 17.8% (in Q3 2014 to Q2 2016) to 29.6% (in Q2 2018 to Q4 2019). Conclusions: NGS utilization trends significantly changed post-NCD, however the rate of change was not significantly different by insurance, indicating private insurers may also be following the guidance of the NCD. We observed an increase in repeat NGS testing, despite the NCD not covering repeat testing with the same NGS test.