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. Health Partners Medicare updates this page as new NCDs are announced.

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:

Seat Elevation Equipment (Power Operated) on Power Wheelchairs (280.16)
Effective 5/16/2023

Effective for services performed 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:

1. 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,
2. 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,
3. 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.

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

Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease (AD) (200.3)
Effective 4/7/2022

Alzheimer’s disease (AD) is a currently irreversible brain disorder that progressively degrades memory, cognitive function, and ability to carry out tasks of daily living. AD is the number one cause of dementia in older Americans. Antiamyloid-beta monoclonal antibodies (antiamyloid mAbs) are laboratory-made proteins designed to bind a specific substance in the body, with the goal of marking it for destruction by the body’s immune system. Scientists design various mAbs as treatments with the goal of targeting and neutralizing or clearing infections (like the COVID-19 virus), cancer cells, and in the case of AD, amyloid accumulation in the brain.

Effective April 7, 2022, the Centers for Medicare & Medicaid Services (CMS) covers Food and Drug Administration (FDA) approved monoclonal antibodies directed against amyloid for the treatment of AD when furnished in accordance with Section B under coverage with evidence development (CED) for patients who have a clinical diagnosis of mild cognitive impairment (MCI) due to AD or mild AD dementia, both with confirmed presence of amyloid beta pathology consistent with AD.

Screening for Lung Cancer with Low Dose CT
Effective 2/10/2022

The Centers for Medicare & Medicaid Services (CMS) has determined that evidence is sufficient to expand the eligibility criteria for Medicare beneficiaries receiving low dose computed tomography (LDCT) for lung cancer screening when the following criteria are met. This final decision lowers the starting age for screening from 55 to 50 years and reducing the tobacco smoking history from at least 30 packs per year to at least 20 packs per year.

Beneficiary eligibility criteria:

• Age 50 – 77 years;
• Asymptomatic (no signs or symptoms of lung cancer);
• Tobacco smoking history of at least 20 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes);
• Current smoker or one who has quit smoking within the last 15 years; and
• Receive an order for lung cancer screening with LDCT

In accordance with the CMS guidance, Health Partners Medicare will cover this service when the conditions apply. Copays are waived when services provided in-network.

Chimeric Antigen Receptor (CAR) T-cell Therapy (NCD 110.24)
Effective for services performed on or after August 7, 2019

The Centers for Medicare & Medicaid Services (CMS) covers autologous treatment for cancer with T-cells expressing at least one chimeric antigen receptor (CAR) when administered at healthcare facilities enrolled in the FDA risk evaluation and mitigation strategies (REMS) and used for a medically accepted indication as defined at Social Security Act section 1861(t)(2) -i.e., is used for either an FDA-approved indication (according to the FDA-approved label for that product), or for other uses when the product has been FDA-approved and the use is supported in one or more CMS-approved compendia.

A person’s immune system contains cells to help fight substances that are foreign to the body, including cancer. These cells are called white blood cells, most of which are lymphocytes. The two main types of lymphocytes are B lymphocytes (B-cells) and T lymphocytes (T-cells). B-cells generate and release antibodies to fight infection, especially bacterial infections, while T-cells employ a number of other mechanisms to fight abnormal cells such as cancer. One type of therapy that leverages the immune system – immunotherapy - is Chimeric Antigen Receptor (CAR) T-cell therapy.

CAR T-cells have been genetically altered in order to improve the ability of the T-cells to fight cancer. The genetic modification creating a CAR can enhance the ability of the T-cell to recognize and attach to a specific protein, called an antigen, on the surface of a cancer cell.

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

Next Generation Sequencing (NGS) (90.2)
Effective January 27, 2020

1. 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:

Patient has:

• either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and,
• not been previously tested with the same test using NGS for the same cancer genetic content, and
• decided to seek further cancer treatment (e.g., therapeutic chemotherapy).

2. Effective for services performed on or after January 27, 2020, CMS has determined that NGS as a diagnostic laboratory test is reasonable and necessary and covered nationally for patients with germline (inherited) cancer, when performed in a CLIA-certified laboratory, when ordered by a treating physician and when all of the following requirements are met:

Patient has:

• 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
• not been previously tested with the same germline test using NGS for the same germline genetic content.

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

 

National Coverage Determination (NCD) for Acupuncture for Chronic Lower Back Pain (cLBP) (30.3.3)
Effective January 21, 2020

Acupuncture is the selection and manipulation of specific acupuncture points by a variety of needling and non-needling techniques.

Effective for services performed on or after January, 21, 2020, CMS will cover acupuncture for Medicare patients with chronic Lower Back Pain. Up to 12 visits in 90 days are covered for Medicare beneficiaries. An additional 8 sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually.

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

 

National Coverage Determination (NCD) for Ambulatory Blood Pressure Monitoring (20.19)
Effective July 2, 2019

Ambulatory Blood Pressure Monitoring (ABPM) is a diagnostic test that allows for the identification of various types of high blood pressure (BP). ABPM devices are small portable machines that are connected to a blood pressure cuff worn by patients that record blood pressure at regular periods over 24 to 48 hours while the patient goes about their normal activities, including sleep. The recording is interpreted by a physician or non-physician practitioner, and appropriate action is taken based on the findings. Diagnosis and treatment of high BP is important for the management of various conditions including cardiovascular disease and kidney disease.

For dates of service on and after July 2, 2019, the Centers for Medicare & Medicaid Services (CMS) believes that the evidence is sufficient to determine that ABPM is reasonable and necessary for the diagnosis of hypertension in Medicare beneficiaries.

For eligible patients, ABPM is covered once per year.

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

 

National Coverage Determination (NCD) for Vagus Nerve Stimulation (VNS) (160.18)
Effective February 15, 2019

Vagus Nerve Stimulation (VNS) is a pulse generator, similar to a pacemaker, that is surgically implanted under the skin of the left chest and an electrical lead (wire) is connected from the generator to the left vagus nerve. Electrical signals are sent from the battery-powered generator to the vagus nerve via the lead. These signals are in turn sent to the brain. The Food and Drug Administration (FDA) approved VNS for treatment of refractory epilepsy in 1997 and for resistant depression in 2005.

Effective for services performed on or after July 1, 1999, VNS is reasonable and necessary for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed.

Effective for services performed on or after February 15, 2019, the Centers for Medicare & Medicaid Services (CMS) will cover FDA-approved VNS devices for treatment resistant depression (TRD) through Coverage with Evidence Development (CED) when offered in a CMS-approved, double-blind, randomized, placebo-controlled trial with a follow-up duration of at least one year with the possibility of extending the study to a prospective longitudinal study when the CMS-approved, double-blind, randomized placebo-controlled trial has completed enrollment, and there are positive interim findings.

VNS is non-covered for the treatment of TRD (treatment resistant depression) when furnished outside of a CMS-approved CED study.

All other indications of VNS for the treatment of depression are nationally non-covered.

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

 

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 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 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 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.

 

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

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.

For help with questions about benefits or using your plan, call Health Partners Medicare 1-866-901-8000 (TTY 1-877-454-8477). From October 1 to March 31, we’re available 8 a.m. to 8 p.m., 7 days a week. And from April 1 to September 30, we’re available 8 a.m. to 8 p.m., Monday to Friday.