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National Coverage Determinations

The Centers for Medicare & Medicaid Services (CMS) sometimes changes the coverage rules that apply to an item or service under Medicare. When this happens, CMS issues a National Coverage Determination (NCD) to explain the change.

NCDs tell you:

  • What benefits and services are covered
  • What benefits and services are changing
  • What Medicare will pay for these items or services

CMS has issued the following National Coverage Determinations: 

National Coverage Determination (NCD) for Next Generation Sequencing (NGS) (90.2)
Effective for services performed on or after March 16, 2018
 

Effective for services performed on or after March 16, 2018, the Centers for Medicare & Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following requirements are met:

1. Patient has:

  • either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and,
  • 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,
  • decided to seek further cancer treatment (e.g., therapeutic chemotherapy).

In accordance with the Centers for Medicare & Medicaid Services guidance, Health Partners Medicare will cover this service when the conditions apply.

 

Implantable Cardiac Defibrillators (ICDs)
Effective Date: For services provided on or after February 15, 2018 

Effective for services performed on or after February 15, 2018, CMS has determined that the evidence is sufficient to conclude that the use of ICDs, (also referred to as defibrillators) is reasonable and necessary:

  1. Patients with a personal history of sustained Ventricular Tachyarrhythmia (VT) or cardiac arrest due to Ventricular Fibrillation (VF).
  2. Patients with a prior MI and a measured Left Ventricular Ejection Fraction (LVEF) ≤ 0.30.
  3. Patients who have severe, ischemic, dilated cardiomyopathy but no personal history of sustained VT or cardiac arrest due to VF, and have NYHA Class II or III heart failure, LVEF < 35%.
  4. Patients who have severe, non-ischemic, dilated cardiomyopathy but no personal history of cardiac arrest or sustained VT, NYHA Class II or III heart failure, LVEF < 35%, been on optimal medical therapy for at least three (3) months.
  5. Patients with documented, familial or genetic disorders with a high risk of life-threatening tachyarrhythmias (sustained VT or VF, to include, but not limited to, long QT syndrome or hypertrophic cardiomyopathy.
  6. Patients with an existing ICD may receive an ICD replacement if it is required due to the end of battery life, Elective Replacement Indicator (ERI), or device/lead malfunction.

In accordance with the Centers for Medicare & Medicaid Services guidance, Health Partners Medicare will cover this service when the conditions apply.

 

Effective 4/10/18, the Centers for Medicare & Medicaid Services (CMS) has added additional coverage criteria to NCD 220.2 - Magnetic Resonance Imaging (MRI). 

CMS determined the evidence is sufficient to conclude that MRI for Medicare beneficiaries with an implanted Pacemaker, Implantable Cardioverter Defibrillator (ICD), Cardiac Resynchronization Therapy Pacemaker (CRT-P), or Cardiac Resynchronization Therapy Defibrillators (CRT-D) is reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act (the Act) under certain circumstances. 

MRI is not covered for patients with metallic clips on vascular aneurysms. 

In accordance with the Centers for Medicare & Medicaid Services guidance, Health Partners Medicare will cover this service when the conditions apply. 

 

Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)
Effective Date: For services provided on or after May 25, 2017

Medicare covers supervised exercise therapy (SET) for treatment of symptomatic peripheral artery disease in people with intermittent claudication (cramping pain in the leg). 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:

  • 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 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, physician assistant or nurse practitioner/clinical nurse specialist trained in both basic and advanced life support techniques

In accordance with the CMS guidance, Health Partners Medicare will cover this service when all the above conditions apply. Copays are waived.

 

Effective January 18, 2017, the Centers for Medicare & Medicaid Services (CMS) covers leadless pacemakers through Coverage with Evidence Development (CED).

CMS covers leadless pacemakers when procedures are performed in Food and Drug Administration (FDA) approved studies. CMS also covers, in prospective longitudinal studies, leadless pacemakers that are used in accordance with the FDA approved label for devices that have either:

  • an associated ongoing FDA approved post-approval study; or
  • completed an FDA post-approval study.

In accordance with the Centers for Medicare & Medicaid Services guidance, Health Partners Medicare will cover this service when the conditions apply.

 

Screening for Hepatitis B Virus (HBV) Infection
Effective Date: September 28, 2016

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:

  • Asymptomatic, non-pregnant adolescents and adults at high risk for HBV infection
  • HBV screening for pregnant women

In accordance with the CMS guidance, Health Partners Plans Medicare will cover this service when the conditions apply. Copays are waived.

 

Effective February 8, 2016: Percutaneous Left Atrial Appendage Closure (LAAC) 

The Centers for Medicare & Medicaid Services (CMS) covers percutaneous LAAC for non-valvular atrial fibrillation through Coverage with Evidence Development when criteria per the National Coverage Determination are met. In accordance with CMS guidance, Health Partners Plans will allow for this service when the specified criteria are met.

 

Screening for Cervical Cancer with Human Papillomavirus (HPV)
Effective Date: For services provided on or after July 9, 2015

Medicare covers a screening pelvic examination and Pap test for all female beneficiaries at 12 or 24 month intervals, based on specific risk factors.

Effective for services performed on or after July 9, 2015, CMS has determined that the evidence is sufficient to add Human Papillomavirus (HPV) testing once every five years as an additional preventive service benefit under the Medicare program for asymptomatic beneficiaries aged 30 to 65 years in conjunction with the Pap smear test.

In accordance with the Centers for Medicare & Medicaid Services guidance, Health Partners Medicare will cover this service when the conditions apply.

 

Lung Cancer Screening
Effective Date: For services provided on or after February 5, 2015

Medicare covers lung cancer screening with Low Dose Computed Tomography (LDCT) once a year for people with Medicare who meet all of these conditions:

  • You are age 55-77
  • You’re either a current smoker or have quit smoking within the last 15 years
  • You have a tobacco smoking history of at least 30 “pack years” (an average of one pack a day for 30 years)
  • You get a written order from your physician or qualified non-physician practitioner

In accordance with the CMS guidance, Health Partners Medicare will cover this service when the conditions above apply.

Note: Before your first lung cancer screening, you’ll need to schedule an appointment with your doctor to discuss the benefits and risks of lung cancer screening. You and your doctor can decide whether lung cancer screening is right for you.

 

Colorectal Cancer Screening — Stool DNA Testing
Effective Date: For services provided on or after October 9, 2014

Medicare covers Cologuard™, a multi-target stool DNA test, as a colorectal cancer screening test once every three years for people who meet all of the following conditions:

  • You are age 50-85
  • You are asymptomatic (have no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test)
  • You are at average risk of developing colorectal cancer (no previous history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer)

In 2015, you pay nothing for this multi-target stool DNA test (Cologuard™).

In accordance with the CMS guidance, Health Partners Medicare will cover this service when all the above conditions apply. No other screening stool DNA tests are currently covered.

 

Hepatitis C Virus (HCV) Screening
Effective Date: For services provided on or after June 2, 2014

Medicare covers one Hepatitis C screening test. Medicare also covers yearly repeat screening for certain people at high risk who meet one of these conditions:

  • You are at high risk because you have a current or past history of illicit injection drug use
  • You had a blood transfusion before 1992
  • You were born between 1945-1965

In accordance with the CMS guidance, Health Partners Medicare will cover this service when the conditions above apply.

 

Cardiac Pacemakers, Single Chamber and Dual Chamber Permanent
Effective Date: For services provided on or after August 13, 2013

Medicare has concluded that implanted permanent cardiac pacemakers, single chamber or dual chamber, are a reasonable and necessary treatment with the following indications:

  • Documented non-reversible symptomatic bradycardia due to sinus node dysfunction, and
  • Documented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block

In accordance with the CMS guidance, Health Partners Medicare will cover this service when the above conditions apply.

For help with questions about benefits or using your plan, call Health Partners Medicare anytime, 24 hours a day, seven days a week, at 1-866-901-8000 (TTY 1-877-454-8477).