National Coverage Determinations

Updates to your Medicare coverage by CMS

Updated January 2020

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

  • Which benefits and services are covered

  • Which benefits and services are changing

  • How much Medicare will pay for an item or service

CDPHP® Medicare Advantage is required to notify members about any NCDs that affect our plan benefits via this website.

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

See our NCD notices below.


Acupuncture for Chronic Low Back Pain

Effective: January 21,2020

CMS will cover acupuncture for chronic low back pain under section 1862(a)(1)(A) of the Social Security Act. Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances:

  • For the purpose of this decision, chronic low back pain (cLBP) is defined as:

    • Lasting 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.

  • An additional eight sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually.

  • Treatment must be discontinued if the patient is not improving or is regressing.

Physicians (as defined in 1861(r)(1)) may furnish acupuncture in accordance with applicable state requirements.

Visit the CMS website for more details.


Decision Memo for Chimeric Antigen Receptor (CAR) T-cell Therapy for Cancers

Effective: 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.

For calendar years 2019 and 2020 only, original fee-for-service Medicare will pay for CAR T-cell therapy for cancer obtained by beneficiaries enrolled in MA plans when the coverage criteria outlined in the NCD is met.

Visit the CMS website for more details.


Vagus Nerve Stimulation (VNS) for Treatment Resistant Depression (TRD) (CAG-00313R2)

Effective: February 15, 2019

CMS is finalizing changes to the vagus nerve stimulation (VNS) NCD (160.18) for VNS for treatment resistant depression (TRD) that will expand Medicare coverage. The scope of this reconsideration is limited to VNS for TRD.

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.

Visit the CMS website for more details.


Magnetic Resonance Imaging (MRI) (CAG-00399R4)

Effective: April 10, 2018

CMS determined the evidence is sufficient to conclude that magnetic resonance imaging (MRI) for Medicare beneficiaries with an implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), or cardiac resynchronization therapy defibrillator (CRT-D) is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member under certain circumstances.

Visit the CMS website for more details.


Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer (CAG-00450N)

Effective: 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 CLIA-certified laboratory, when ordered by a treating physician and when all of the qualifying requirements are met.

Visit the CMS website for more details.


Implantable Cardioverter Defibrillators

Effective: February 15, 2018

The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to conclude that the use of implantable cardioverter defibrillators (ICDs, also referred to as defibrillators) is reasonable and necessary for the treatment of illness or injury or to improve the functioning of a malformed body member. CMS is finalizing relatively minimal changes to the 20.4 NCD that reflect the 2005 reconsideration.

Visit the CMS website for more details.


Leadless Pacemakers

Effective: January 18, 2017

TCMS covers leadless pacemakers as part of clinical research studies. The study must meet certain criteria and be approved by CMS and the Food and Drug Administration (FDA).The leadless pacemaker eliminates some causes of complications with traditional pacing systems. This summarizes CMS transmittal 201.

Visit the CMS website for more details.


Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)

Effective: May 25, 2017

The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to cover supervised exercise therapy (SET) for beneficiaries with intermittent claudication (IC) for the treatment of symptomatic peripheral artery disease (PAD). Up to 36 sessions over a 12 week period are covered if all of the following components of a SET program are met. For calendar years 2017 and 2018 only, original fee-for-service Medicare will pay for reasonable and necessary items and services obtained by beneficiaries enrolled in MA plans.

Visit the CMS website for more details.