National Coverage Determinations

National Coverage Determinations

(Updated April 2013)
NCDs are coverage updates made by CMS through an evidence-based process, with opportunities for public participation. These updates typically occur outside the regularly scheduled Annual Election Period, which begins each year in October. CDPHP Medicare Choices notifies members about all NCDs that affect our plan benefits, including via this website.

If you have any questions about your CDPHP Medicare Choices coverage, please contact Member Services at the number on your ID card. 

CMS HAS MADE THE FOLLOWING BENEFIT CHANGES FOR ALL MEDICARE PLANS:

Ocular Photodynamic Therapy (OPT) With Verteporfin
Effective: April 3, 2013
Description: The Centers for Medicare & Medicaid Services (CMS) has expanded coverage of ocular photodynamic therapy (OPT) with verteporfin for “wet” age-related macular edema (AMD).  Previously, fluorescein angiography (FA) testing was required for coverage of follow-up treatments.  They have revised the requirements for testing to permit either optical coherence tomography (OCT) or FA to assess treatment response.  All other coverage criteria continue to apply.

Visit the CMS website for more details.

Oncologic Uses of Radiopharmaceuticals
Effective: March 7, 2013
Description: CDPHP has been granted jurisdiction by CMS regarding coverage for radiopharmaceuticals used for positron emission tomography (PET) oncologic imaging. CDPHP currently provides reimbursement for radiopharmaceuticals only when the code is defined as therapeutic. Except in limited situations, reimbursement is not provided for radiopharmaceuticals defined as diagnostic. CMS may make future national coverage decisions on the use of any radiopharmaceuticals, which would supersede this determination.

Visit the CMS website for more details.

Autologous Platelet-Rich Plasma
Effective: August 2, 2012
Description: Autologous platelet-rich plasma (PRP) can be covered for patients who have chronic non-healing diabetic, pressure, and/or venous wounds and are enrolled in a clinical research study that addresses specified questions using validated and reliable methods of evaluation. Clinical study applications for coverage pursuant to this National Coverage Determination (NCD) must be received by August 2, 2014.

Visit the CMS website for more details.

Adult Liver Transplant – Additional Malignancies Now Covered
Effective: June 21, 2012
Description: The Centers for Medicare & Medicaid Services (CMS) has issued a final decision memo stating that health plans may now consider liver transplant coverage for the following malignancies: (1) extrahepatic unresectable cholangiocarcinoma (CCA); (2) liver metastases due to a neuroendocrine tumor (NET); and (3) hemangioendothelioma (HAE).

Visit the CMS website for more details.

Extracorporeal Photopheresis
Effective: April 30, 2012
Description: Extracorporeal photopheresis (EP) can be covered when administered as part of a sanctioned clinical research study involving Medicare members who have undergone a lung allograft and subsequently developed progressive bronchiolitis obliterans syndrome refractory to immunosuppressive drug treatment.

Visit the CMS website for more information. 

Transcatheter Aortic Valve Replacement
Effective: May 1, 2012
Description: Transcatheter Aortic Valve Replacement (TAVR) using the Edwards Sapien^® heart valve replacement system can be covered for Medicare members suffering from aortic stenosis. Previously, surgical repair of aortic stenosis was covered only when performed via open heart surgery. 

Certain provider, facility, and data collection criteria must be met as a condition of coverage:

• The procedure must use a device approved by the FDA.
• Two cardiac surgeons must have reviewed the patient's suitability for surgery.
• The patient must be under the care of a multidisciplinary heart team, and the facility must have the appropriate infrastructure to perform transcatheter aortic valve implantation (TAVI).
• Interventional cardiologists and cardiac surgeons must jointly participate in the intraoperative technical aspects of the procedure.
•  The hospital in which it is performed must participate in a prospective, national, audited registry that follows the patient for at least one year but tracks outcomes for five years.

More information can be found on the CMS website.

Transcutaneous Electrical Nerve Stimulation (TENS)
Effective: June 8, 2012
Description: Although CMS has determined that transcutaneous electrical nerve stimulation (TENS) will be covered only for those Medicare patients who are enrolled in a prospective clinical study with a randomized controlled design, CDPHP will continue to cover TENS units for all lines of business, subject to criteria and coverage guidelines, and has removed the prior authorization requirement.   

Visit the CMS website for more information.

Bariatric Surgical Procedures
Effective: June 27, 2012
Description: Stand-alone laparoscopic sleeve gastrectomy can be covered for the treatment of co-morbid conditions related to obesity for Medicare beneficiaries. This approach is in addition to the following procedures already approved by CMS: open and laparoscopic Roux-en-Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB); and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS).  For each of these procedures, the following conditions must be satisfied:

• The beneficiary has a body-mass index (BMI) ≥ 35 kg/m²
• The beneficiary has at least one co-morbidity related to obesity
• The beneficiary has been previously unsuccessful with medical treatment for obesity

More information can be found by logging in to the secure member site on cdphp.com and clicking the My Resources tab or on the CMS website.

Intensive behavioral counseling for obesity
Effective: November 29, 2011
Description: Intensive behavioral (medical nutrition) therapy for obesity (BMI of 30 kg/m² or higher) when provided by a qualified primary care physician, or other primary car practictioner, in a primary case setting as follow:

• One face-to-face visit every week for the first month;
• One face-to-face visit every other week for months two through six;
• One face-to-face visit every month for months seven through twelve, if the enrollee has achieved a minimum 3 kg reduction in weight during the first six months of intensive therapy.

Y0019_13_10035REV CMS Approved 1/8/13