The Centers for Medicare & Medicaid Services (CMS) sometimes change the coverage rules that apply to an item or service. When this happens, CMS issues a National Coverage Determination (NCD). It tells us:
See our NCD notices below.
This is effective for service on or after April 10, 2018.
CMS determined that MRI for Medicare beneficiaries with the below devices is reasonable and necessary under certain circumstances.
CMS will expand coverage:
CMS will also remove the Coverage with Evidence Development (CED) requirement.
This summarizes CMS transmittal 208.
This is effective for service on or after March 16, 2018.
The Centers for Medicare & Medicaid Services (CMS) reviewed the evidence for laboratory diagnostic tests using NGS in patients with cancer. They determined that some tests could improve health outcomes for Medicare beneficiaries with advanced cancer. Testing will be covered for beneficiaries with:
The test must be ordered by the treating physician, performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, and have all of the following requirements met:
This summarizes CMS transmittal 215 (replacing 214 and 210).
This is effective for service on or after February 15, 2018.
The implantable automatic defibrillator is an electronic device designed to detect and treat life-threatening tachyarrhythmias.
CMS will cover ICDs for the following patient indications.
Additional indications effective for services performed on or after October 1, 2003:
This summarizes CMS transmittal 213 (replacing 209 & 211).
This is effective for services on or after May 25, 2017.
The Centers for Medicare and Medicaid Services (CMS) issued an NCD to cover SET for beneficiaries with intermittent claudication (IC) for the treatment of symptomatic PAD.
SET involves the use of intermittent walking exercise, which alternates periods of walking to moderate-to-maximum claudication, with rest.
SET has been recommended as the initial treatment for patients suffering from IC, the most common symptom experienced by people with PAD.
Up to 36 sessions over a 12-week period are covered if all of the following components of a SET program are met. The SET program must:
This summarizes CMS transmittal 207 (replacing 204, 205 and 206).
This is effective for services on or after April 3, 2017.
Local Medicare administrators will decide if they’ll cover topical oxygen for the treatment of chronic non-healing wounds.
This summarizes CMS transmittal 203.
This affects services given on or after January 18, 2017.
CMS covers leadless pacemakers as part of clinical research studies. The study must meet certain criteria and be approved by CMS and the Food and Drug Administration (FDA).
The leadless pacemaker eliminates some causes of complications with traditional pacing systems.
This summarizes CMS transmittal 201.
This affects services given on or after December 7, 2016.
This back surgery will be covered if you are part of an approved clinical trial.
Other types of surgery for your condition are not covered. This includes endoscopically assisted laminotomy/laminectomy and other open lumbar decompression procedures.
This is now expanded to cover a prospective longitudinal study of PILD procedures using an FDA-approved/cleared device if the study completed a CMS-approved randomized clinical trial that met established criteria.
This summarizes CMS transmittal 200 (replacing 167 and 199).
The Centers for Medicare & Medicaid Services (CMS) has reviewed the updated US Preventive Services Task Force (USPSTF) guidance on screening for Hepatitis B Virus (HBV) infection. Effective September 28, 2016, Medicare will cover HBV screening when ordered by a primary care provider for members who meet one of the following conditions:
This summarizes CMS transmittal 195.
This affects services given on or after February 8, 2016.
Percutaneous LAAC will be covered only through Coverage with Evidence Development (CED) when the patient both:
If you think you qualify, speak with your physician.
To receive coverage, you must have:
This summarizes CMS transmittal 192.
This affects services given on or after January 27, 2016.
Expanded coverage of allogenic (donor) hematopoietic stem cell transplantation (HSCT) for:
In the HSCT procedure, a doctor takes part of a healthy donor's stem cell or bone marrow and prepares it for intravenous infusion (usually an injection using an IV.) It also includes using high dose chemotherapy and/or radiotherapy before the actual transplant.
This NCD expands coverage for donor HSCT items and services. They’ll only be covered by Medicare if it’s provided in a Medicare-approved clinical study under Coverage with Evidence Development (CED.) When bone marrow or peripheral blood stem cell transplantation is covered, all necessary steps are included in coverage.
This summarizes CMS transmittal 193 (replacing 191).
This affects services given on or after July 29, 2015.
Revised features for covered SGDs include speech generated using one of the following methods:
Other covered features of the device include the:
The cost of non-covered features is the responsibility of the beneficiary. However, in some cases, Medicare administratiors may allow payment for some non-covered SGDs and features. They decide this based on what they find is reasonable and necessary.
This summarizes CMS transmittal 184.
This affects services given on or after July 9, 2015.
HPV testing is now an additional preventive service benefit under the Medicare program. We will cover this testing:
To get coverage, you must receive your screening for cervical cancer:
This summarizes CMS transmittal 189.
This affects services given on or after April 13, 2015.
You can be tested for early detection of HIV if you’re:
We will only cover one HIV screening per year if:
This summarizes CMS transmittal 190.
This affects services given on or after February 5, 2015.
To receive these services, as a Medicare beneficiary, you must:
This affects services given on or after January 13, 2015.
CMS decided that it’s not appropriate to supply a National Coverage Determination for MTWA testing using the modified moving average (MMA) method. The MMA method is a type of heart scan that evaluates patients at risk for sudden cardiac death (SCD), also called cardiac arrest. Because of this decision, this kind of testing will be covered in some areas. Local contractors will decide whether this testing receives Medicare coverage in their service areas. As a Medicare Advantage Organization, Aetna will follow your local Medicare administrator’s policy on covering your heart scan.
This summarizes CMS transmittal R182.
This affects services given on or after December 18, 2014. Unless noted, the effective date is the date of service.
These sections will be removed from Pub. 100-03, Medicare National Coverage Determinations Manual.
This doesn’t mean the services aren't covered. We’ll still review services that are reasonable and necessary for your diagnosis or condition.
This affects services given on or after October 9, 2014.
Medicare Part B covers CologuardTM – a multitarget stool DNA test – once every three years, for Medicare beneficiaries who meet all of the following standards:
There is no coinsurance or deductible for the tests that are administered once every three years.
This summarizes CMS transmittal 183.
This affects services given on or after October 01, 2014.
CMS has advised a doctor’s prescription and additional documents must explain the medical need for a hospital bed. Acceptable reasons explaining the medical need include:
A variable-height hospital bed may also be medically necessary and covered for any of the following conditions:
This affects services given on or after August 7, 2014.
Medicare will cover your heart valve surgery if all these apply:
This summarizes CMS transmittal 178.
This affects services given on or after June 2, 2014.
If your doctor says you’re at high risk, CMS will cover a blood test to see if you have the hepatitis C virus. To be at high risk, you either:
CMS must approve the person who does your blood test. CMS will cover the blood test each year if you:
This summarizes CMS transmittal 174.
This affects services given on or after May 6, 2014.
Intensive Cardiac Rehabilitation Program - Benson-Henry Institute Cardiac Wellness Program
If your doctor wants you to take part in this heart wellness program, Medicare will cover it.
This summarizes CMS transmittal 175.
This affects services given on or after May 29, 2013. Updated April 14, 2014.
Aprepitant is a drug used with two others. It prevents nausea and vomiting caused by chemotherapy (chemo).
We cover the oral form, the form you take by mouth, only in certain cases. For example, if your doctor orders it for you right before and within 48 hours after your chemo treatment, it is covered. If you have Medicare Part D, other uses of this oral drug may be covered.
April 4, 2005: CMS announced a NCD for the use of the oral three-drug regimen of aprepitant, a 5HT3 antagonist, and dexamethasone. The regimen is for patients who are receiving the below nine anticancer chemo agents.
April 14, 2014: CMS released an additional update to the April 4, 2005 NCD. It is retroactive to May 29, 2013.
The update added more drugs to the existing list of approved anticancer chemo agents.
We now also cover the drugs below for the oral antiemetic three-drug regimen of an oral aprepitant, an oral 5HT3 antagonist and oral dexamethasone:
This summarizes CMS transmittal 165. It replaces and rescinds CMS transmittal 163.
This affects services given on or after February 18, 2014.
Medicare will cover your heart rehabilitation if you have chronic heart failure. This condition must be stable. This means you have taken drugs for your condition for at least six weeks and still have symptoms.
This summarizes CMS transmittal 171.
This affects services given on or after January 27, 2014.
Medicare covers one test a year to see if you have an enlarged blood vessel in your belly. This test is painless. You lie on your back and a technician uses a camera to take images. You need your doctor’s OK to have this test.
Medicare also covers one test a year to see if you have colorectal cancer. For this test, you put a tiny sample of your stool on a special card or cloth. A lab tests it. You need your doctor’s OK to have this test.
This summarizes CMS transmittal 176.
This affects services given on or after October 30, 2013.
Medicare will cover your heart pump if:
Medicare must approve the hospital you’ll use for this procedure.
Are you waiting for a heart transplant? You must be on an active wait list. It’s maintained by the Organ Procurement and Transplantation Network.
This summarizes CMS transmittal R172.
This affects services given on or after September 27, 2013.
Prior to 9/27/2013, Medicare didn't cover positron emission tomography (PET) beta amyloid imaging (also referred to as PET amyloid-beta (Aβ), based on a longstanding general non-coverage of PET.
Effective 9/27/2013 Medicare will cover one PET Aβ imaging scan if you’re enrolled in certain clinical trials or research studies.
Review more information about this NCD. Clinical study, clinical trial and research study criteria begin on page 7.
This affects services given on or after September 24, 2013.
CMS has removed the facility certification requirement, which required that these bariatric procedures were covered only when performed at facilities that are:
Any certifications for other surgical procedures still apply.
This affects services given on or after August 13, 2013.
CMS has advised on the treatment of non-reversible symptomatic bradycardia (slow heart rate). CMS has guided that implanted permanent cardiac pacemakers, single- or dual-chamber, are reasonable and necessary for this condition.
Symptoms of bradycardia happen when your heart rate is less than 60 beats per minute. Symptoms include syncope (fainting), seizures, congestive heart failure, dizziness, or confusion.
This affects services given on or after June 11, 2013.
CMS covers 3 PET scans after you finish your therapy for solid tumors. The scans must be used as a guide for treating your same cancer diagnosis. If you have more than 3 PET scans, your local Medicare administrator will decide if they can be covered.
This affects services given on or after April 3, 2013.
CMS will cover treatment for neovascular age-related macular degeneration with injections of verteporfin. This treatment blocks the development of new blood vessels and leakage from abnormal vessels. In follow-up visits, your doctor will assess how the treatment is working. He/she will do this with either an optical coherence tomography (OCT) or fluorescein angiography.
This services given on and after August 2, 2012.
CMS will cover PRP for the treatment of chronic non-healing diabetic, venous and/or pressure wounds onlywhen provided under a clinical research study that meets specific requirements. The requirements are that the study assess the health outcomes of PRP for the treatment of chronic non-healing diabetic, venous and/or pressure wounds.
This affects services given on or after June 27, 2012.
Laparoscopic Sleeve Gastrostomy (LSG), including:
Covers stand-alone laparoscopic sleeve gastrostomy (LSG) for treating other qualified medical conditions related to obesity. Available to Medicare beneficiaries who meet all of the following conditions:
Procedure will only be covered when performed at facilities that are certified by either:
This affects services given on or after June 21, 2012.
Covered if you have any of the following:
The transplant must be performed at an approved liver transplant center. This change does not apply to any other malignancies.
This affects services on or after June 8, 2012.
This affects services on or after May 1, 2012.
Covered if you’re entered into a qualified national registry and:
Two heart surgeons must examine you before you receive the TAVR to see if it will work for you.
This affects services given on or after April 30, 2012.
The Centers for Medicare and Medicaid Services (CMS) have added coverage for extracorporeal photopheresis treatment. This is for people who get bronchiolitis obliterans syndrome (BOS) after a lung transplant. You’ll need to enroll in certain clinical research studies for this BOS treatment to be covered. The treatment may help your immune system fight illness better. This study will be used to see if the treatment can improve your health in the following areas:
Extracorporeal photopheresis can be used to treat bronchiolitis obliterans syndrome (BOS) after a lung transplant. It must be provided as part of a clinical research study. These studies must meet specific requirements and be approved on or before April 30, 2014. If no studies are approved by that date, coverage will remain as it was before April 30, 2012.
CMS has added coverage for new preventive services and health risk assessments to the annual wellness visit benefit. This coverage is now available for all Medicare Advantage members. These services:
You may have to pay cost sharing if you use an out-of-network provider.
This affects services on or after November 29, 2011.
This therapy includes:
This affects services on or after November 8, 2011.
Includes one face-to-face risk reduction visit annually.
This affects services on or after November 8, 2011.
Includes two face-to-face visits annually. Also covers the laboratory screening for chlamydia, gonorrhea, syphilis and hepatitis B.
This affects services on or after October 14, 2011.
If you screen positive, up to four brief face-to-face behavioral counseling meetings are covered annually.
This affects services on or after October 14, 2011.
Covered if done in a primary care setting that has staff-assisted depression care supports in place.
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