National Coverage Determination (NCD) notices

This affects services given on or after January 21, 2020

Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD’s) that affect coverage for treatment. The recent NCD changes are as follows:

• CMS will cover acupuncture for chronic low back pain (cLBP) effective for claims with dates of service on and after January 21, 2020.

This NCD expands coverage for acupuncture services specifically targeted for chronic low back pain. Medicare determined it will cover acupuncture for cLBP up to 12 visits in 90 days. These services will only be covered by Medicare if cLBP:

• lasts 12 weeks or longer

• nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc.

• disease); 

• not associated with surgery; and

• not associated with pregnancy 

If you think you qualify, speak with your physician.

This summarizes CMS transmittal R10128NCD

This affects services given 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:

• recurrent, relapsed, refractory or metastatic cancer

• advanced stages III or IV cancer if the beneficiary either:

   

  • has not been previously tested using the same NGS test for the same primary diagnosis of cancer or 

  • will get repeat testing using the same NGS test only when the treating physician gives a new primary cancer diagnosis and there will be further cancer treatment (e.g., therapeutic chemotherapy) 

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:

• Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and,

• an FDA-approved or -cleared indication for use in that patient’s cancer; and,

• results provided to the treating physician for management of the patient using a report template to specify treatment options 

This summarizes CMS transmittal R210NCD

This is effective for service 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 R203NCD

This affects services given on or after April 10, 2018

Medicare will allow for coverage of MRI for beneficiaries under certain conditions with any of the following: implanted pacemaker, implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), or cardiac resynchronization therapy defibrillator (CRT-D).

If you think you qualify, speak with your physician.

This summarizes CMS transmittal R208NCD

This affects services given on or after January 27, 2016

 
Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD’s) that affect coverage for treatment done as part of special studies (Coverage with Evidence Development/CED, Medicare approved studies). These changes only apply to members involved in the special studies. The recent NCD changes are as follows:

• Expanded coverage for donor stem cell transplant (allogenic hematopoietic stem cell transplant) for sickle cell disease, certain diseases of the blood cells (myelofibrosis, multiple myeloma), other rare diseases. In a donor stem cell transplant, a doctor takes part of a healthy donor’s stem cell or bone marrow. This is then specially prepared and given to a patient through a tube in a vein (intravenous infusion). The patient also receives high dose chemotherapy (such as certain cancer drugs) and/or radiation treatments before getting this transplant through the vein.

This NCD expands coverage for donor HSCT items and services. These services will only be covered by Medicare if they are 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 required steps are included in coverage. If you think you qualify, speak with your physician.

This summarizes CMS transmittal R191NCD.

This affects services given on or after February 8, 2016

 
Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD’s) that affect coverage for treatment done as part of special studies (Coverage with Evidence Development/CED, Medicare approved studies). These changes only apply to members involved in the special studies. The recent NCD changes are as follows:

• Coverage will be approved for a special heart procedure (Left Atrial Appendage Closure, LAAC, if the device planned for use has FDA approval; and

• You have a specific type of irregular heart beat (Non-Valvular Atrial Fibrillation, NVAF; and

• You meet all the other specified conditions of the Medicare approved study. 

These services will only be covered by Medicare if they are provided in a Medicare-approved clinical study under Coverage with Evidence Development (CED). If you think you qualify, speak with your physician.

This summarizes CMS transmittal R192NCD.

This affects services given on or after October 9, 2014

 
Cologuard is a test that is performed on a stool sample to check for colon cancer. You no longer need authorization from your health plan before you have this test done.

This summarizes CMS transmittal R183NCD.

This affects services given on or after August 30, 2016

 
Centers for Medicare and Medicaid Services (CMS) recently released a notice in response to public questions around gender reassignment surgeries. This notice restates that there are no national CMS coverage guidelines for this service. Coverage decisions for this type of surgery are made by your local Plan, according to your benefits and your Plan’s medical necessity guidelines. If you have any questions about your coverage for this type of surgery, please contact Member Services at number on your Member ID.

This summarizes CMS transmittal R194NCD.

This affects services given on or after December 7, 2017.

 
Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD’s) that affect coverage for treatment done as part of special studies (Coverage with Evidence Development/CED, Medicare approved studies). These changes only apply to members involved in the special studies. The recent NCD changes are as follows:

• You are having surgery on your lower spine where the surgeon uses a very small incision and surgery is guided with imaging (x-ray) assistance (often referred to as “Percutaneous Image-guided Lumbar Decompression”/PILD).

• You have a condition where the open spaces of your spine are narrowed and this puts pressure on your spinal cord or nerves (“Lumbar Spinal Stenosis”) and you have not had relief with non-surgical treatments.

• You meet all the other specified conditions of the Medicare approved study. 

These services will only be covered by Medicare if they are provided in a Medicare-approved clinical study under Coverage with Evidence Development (CED). If you think you qualify, speak with your physician.

This summarizes CMS transmittal R196NCD.

This affects services given on or after January 18, 2017

 
Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD’s) that affect coverage for treatment done as part of special studies (Coverage with Evidence Development/CED, Medicare approved studies). These changes only apply to members involved in the special studies. The recent NCD changes are as follows:

Medicare will cover placement of a “leadless pacemaker” if you are enrolled in a special approved clinical study. A leadless pacemaker is placed without the need for a device pocket and insertion of a pacing lead which are parts of traditional pacing systems. You should speak with your doctor if you think you qualify to be a participant in an approved clinical study to receive this device.”

This summarizes CMS transmittal R201NCD.

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.

The SET program must:

• Consist of sessions lasting 30-60 minutes, comprising a therapeutic exercise-training program for PAD in patients with claudication

• Be conducted in a hospital outpatient setting, or a physician’s office

• Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD 

• Be under the direct supervision of a physician (as defined in Section 1861(r)(1)) of the Social Security Act (the Act), physician assistant, or nurse practitioner/clinical nurse specialist (as identified in Section 1861(aa)(5) of the Act)) who must be trained in both basic and advanced life support techniques.

This summarizes CMS transmittal R207NCD.

Effective for items on or after May 16, 2023, power seat elevation equipment is reasonable and necessary for individuals using complex rehabilitative power-driven wheelchairs, when the following conditions are met.

1. The individual has undergone a specialty evaluation that confirms the individual’s ability to safely operate the seat elevation equipment in the home. This evaluation must be performed by a licensed/certified medical professional such as a physical therapist (PT), occupational therapist (OT), or other practitioner, who has specific training and experience in rehabilitation wheelchair evaluations; and,
2. At least one of the following apply:
3. The individual performs weight bearing transfers to/from the power wheelchair while in the home, using either their upper extremities during a non-level (uneven) sitting transfer and/or their lower extremities during a sit to stand transfer. Transfers may be accomplished with or without caregiver assistance and/or the use of assistive equipment (e.g. sliding board, cane, crutch, walker, etc.); or,
4. The individual requires a non-weight bearing transfer (e.g. a dependent transfer) to/from the power wheelchair while in the home. Transfers may be accomplished with or without a floor or mounted lift; or,
5. The individual performs reaching from the power wheelchair to complete one or more mobility related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming and bathing in customary locations within the home. MRADLs may be accomplished with or without caregiver assistance and/or the use of assistive equipment.

This summarizes CMS Transmittal 12183 (NCD 280.16)