National Coverage Determination

Below are national coverage determination updates released since January 2016. Click the "view details" button to read more about the determination and what has changed.

Below are current national coverage determination updates. Click the "view details" button to read more about the determination and what has changed.

National Coverage Determination Notifications
Posted Coverage Determination Clinical Trial  
4/3/2017Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Oxygen) (CAG-00060R)

The Centers for Medicare & Medicaid Services (CMS) received a reconsideration request to remove the coverage exclusion of Continuous Diffusion of Oxygen Therapy (CDO) from NCD Manual 20.29, Section C.
YesView Details
7/1/2016Stem Cell Transplantation Formerly 110.8.1 (110.23)

Transmittal 191 from 4/29/2016 has been rescinded and replaced by Transmittal 193, dated 7/1/2016 providing clarifying language referring to the Pub. 100-03 NCD manual, under Summary of Changes. No other changes. (TN 193 ) (CR9620)
YesView Details
6/1/2016Counseling to Prevent Tobacco Use (210.4.1)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
NoView Details
6/1/2016Cochlear Implantation (50.3)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
NoView Details
6/1/2016Aprepitant for Chemotherapy-Induced Emesis (110.18)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
NoView Details
6/1/2016Smoking and Tobacco-Use Cessation Counseling (210.4)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
NoView Details
6/1/2016Percutaneous Transluminal Angioplasty (PTA) (20.7)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
NoView Details
6/1/2016Mammograms (220.4)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
NoView Details
6/1/2016Implantable Automatic Defibrillators (20.4)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
YesView Details
6/1/2016Hyperbaric Oxygen Therapy (20.29)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
NoView Details
6/1/2016Heart Transplants (260.9)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
NoView Details
6/1/2016Cryosurgery of Prostate (230.9)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
NoView Details
6/1/2016Colorectal Cancer Screening Tests (210.3)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed.(TN 1672 )
NoView Details
5/1/2016Smoking and Tobacco-Use Cessation Counseling (210.4)

7TH maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Percutaneous Transluminal Angioplasty (PTA) (20.7)

7TH maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Mammograms (220.4)

7TH maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Implantable Automatic Defibrillators (20.4)

7TH maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
YesView Details
5/1/2016Hyperbaric Oxygen Therapy (20.29)

7TH maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Heart Transplants (260.9)

7TH maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Cryosurgery of Prostate (230.9)

7TH maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Counseling to Prevent Tobacco Use (210.4.1)

7TH maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Colorectal Cancer Screening Tests (210.3)

7TH maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Cochlear Implantation (50.3)

7th maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Aprepitant for Chemotherapy-Induced Emesis (110.18)

7th maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Percutaneous Left Atrial Appendage Closure (LAAC) (20.34)

CMS has issued a National Coverage Determination for Left Atrial Appendage Closure through Coverage with Evidence Development (CED) for patients that meet approved coverage criteria using an FDA approved device. Effective 2/8/2016 Implementation date: 10/03/2016 ((TN192) (CR9638)
No CDE StudyView Details
4/1/2016Stem Cell Transplantation Formerly 110.8.1 (110.23)

After 1/27/2016 the use of allogenic HSCT to treat Multiple Myeloma, Myelofibrosis and Sickle Cell Disease will be covered by Medicare if provided in a Medicare-approved clinical study under the CDE paradigm. This transmittal also updates diagnosis codes to ICD-10. See Pub. 100-3, chapter 1, section 110.23 of the NCD Manual for further information. Implementation Date: 10/03/2016. (TN 191 ) (CR9620)
YesView Details
4/1/2016Vagus Nerve Stimulation (VNS) (160.18)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Transcatheter Mitral Valve Repair (TMVR) (20.33)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
YesView Details
4/1/2016Sacral Nerve Stimulation for Urinary Incontinence (230.18)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Percutaneous Image-Guided Breast Biopsy (220.13)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Mammograms (220.4)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Lung Cancer Screening with Low Dose Computed Tomography (LDCT) (210.14)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Hyperbaric Oxygen Therapy (20.29)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Extracorporeal Photopheresis (110.4)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
YesView Details
4/1/2016Deep Brain Stimulation for Essential Tremor and Parkinson’s disease (160.24)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Colorectal Cancer Screening Tests (210.3)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Bone (Mineral) Density Studies (150.3)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Aprepitant for Chemotherapy-Induced Emesis (110.18)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Adult Liver Transplantation (260.1)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
2/1/2016Screening for Cervical Cancer with Human Papillomavirus (HPV) (210.2.1)

Effective 7/9/15 CMS feels evidence is sufficient to add HPV testing with guidelines. Implementation date 03/07/2016 (TN 189 ) (CR9434)
NoView Details
2/1/2016Screening for the Human Immunodeficiency Virus (HIV) Infection (210.7)

CMS feels there is adequate evidence to screen for HIV infection in all people between the ages of 15-65 years who are eligible for benefits under Part A or enrolled in Part B. Effective 04/13/2015 implementation date 3/1/2016. (TN 190 ) (CR9403)
NoView Details


CMS NCD Updates for Clinical Diagnostic Laboratory Services

Please use this link to see the updates published January 2016.




Clinical Trials:

For clinical trials covered under the Clinical Trials National Coverage Determination 310.1 (NCD) (NCD manual, Pub. 100-03, Part 4, section 310), original Medicare covers the routine costs of qualifying clinical trials for all Medicare enrollees, including those enrolled in Senior Health Plan, as well as reasonable and necessary items and services used to diagnose and treat complications arising from participating in qualifying clinical trials. All other original Medicare rules apply.

You may refer to Medicare's Clinical Trial Policy at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=1&ncdver=2&bc=BAABAAAAAAAA for more information on the definition of routine costs and the clinical trial Medicare qualification process. Medicare's Clinical Trial Policy does not withdraw Medicare coverage for items and services that may be covered according to Local Coverage Determinations (LCDs) or the regulations on category B investigational device exemptions (IDE) found in 42 CFR 405, Subpart B, 411.15, and 411.406.

Senior Health Plan will pay the enrollee the difference between original Medicare cost-sharing incurred for qualified clinical trial items and services and Senior Health Plan's in-network cost-sharing for the same category of items and services. This cost-sharing reduction requirement applies to all qualifying clinical trials as defined in the NCD manual, Pub. 100-03, Part 4, section310.1. Senior Health Plan may not choose the clinical trial or clinical trial items and services to which this policy applies. Senior Health Plan owes the difference even if the enrollee has not yet paid the clinical trial provider. Additionally, the enrollee's in-network cost-sharing portion also must be included in the plan's out-of-pocket maximum calculation.

To be eligible for reimbursement, an enrollee (or providers acting on the enrollee's behalf) must notify Senior Health Plan that he or she has received a qualified clinical trial service and provide documentation of the cost-sharing incurred, such as a provider bill. Senior Health Plan is also permitted to seek the enrollee's original Medicare cost-sharing information directly from clinical trial providers.

Senior Health Plan enrollees are free to participate in any qualifying clinical trial that is open to beneficiaries in original Medicare. If Senior Health Plan decides to conduct its own clinical trial, Senior Health Plan will explain the benefits of participating in its clinical trial; however, Senior Health Plan may not require prior authorization for participation in a Medicare-qualified clinical trial not sponsored by Senior Health Plan, nor may it create impediments to an enrollee's participation in a non-plan-sponsored clinical trial, even if Senior Health Plan believes it is sponsoring a clinical trial of a similar nature. Examples of impediments to an enrollee's participation include, but are not limited to, requiring enrollees to pay the original Medicare cost-sharing amount for routine care services before being compensated by Senior Health Plan for the difference or unduly delaying any required cost-sharing refund. Enrollees retain the right to choose the clinical trial(s) in which they wish to participate. However, Senior Health Plan may request, but not require, enrollees to notify the plan in advance when they choose to participate in Medicare-qualified clinical trials.


Disclaimers

  • You may join or leave a plan only at certain times. Please call Senior Health Plan at the telephone number listed in the previous section of this web page or 1-800-MEDICARE (1-800-633-4227) for more information. TTY users should call 1-877-486-2048. You can call this number 24 hours a day, seven days a week.
  • You can join Senior Health Plan if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End Stage Renal Disease are generally not eligible to enroll in Senior Health Plan unless they are members of our organization and have been since their dialysis began.
  • Senior Health Plan has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. You can ask for a current Provider Directory for an up-to-date list or search the Senior Health Plan provider directory on this website. If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither Senior Health Plan nor Original Medicare will pay for these services.
  • You must continue to pay your Medicare Part B premium, even if the Senior Health Plan premium is $0.