Member Notification of Medicare National Coverage Determination (NCD)
What is This Notice?
From time to time, the federal agency that runs Medicare announces new information about coverage under the program. The Medicare program requires us to notify members of this information on our website and in our member newsletter.
What Does This Mean to Me?
This is an announcement of new coverage rules. The new rules do not affect all members.
What Should I Do If I Have Questions?
If you have a question about these changes or about how we will cover these benefits, please contact Customer Service.
What are the new coverage rules?
The Centers for Medicare & Medicaid Services (CMS) covers implantable pulmonary artery pressure sensor(s) (IPAPS) for heart failure (HF) management under Coverage with Evidence Development (CED) according to the provisions outlined in Implantable Pulmonary Artery Pressure Sensors for Heart Failure Management (CAG-00466N).
Effective for claims with dates of service on or after September 30, 2024, The Centers for Medicare and Medicaid Services (CMS), will cover the costs of Pre-Exposure Prophylaxis (PrEP) drugs that can prevent Human Immunodeficiency Virus (HIV) in individuals who are at increased risk of contracting the virus. This risk is determined by the patient's physician or health care provider based on the person's medical history.
In addition, the insurance will also cover the costs of providing these anti-HIV drugs, which include supplying, dispensing, and administering them via an injection if necessary.
Apart from this, individuals who are being assessed for or using these drugs can get coverage for additional preventive services. This includes:
- Counseling: Up to eight sessions every year to assess HIV risk, reduce it, and maintain medication adherence. These sessions should be provided by a physician or skilled health care provider when the individual is alert and able to comprehend.
- HIV tests: Up to eight screening tests every 12 months.
- A one-time screening for hepatitis B virus (HBV).
The condition is that these tests should be done using approved laboratory and point of care tests, following FDA guidelines and the Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations.
For this service, patients won't have to pay the usual share of the cost (coinsurance) and meeting the usual deductible under their Medicare Part B coverage.
Visit Pre-Exposure Prophylaxis (PrEP) for Human Immunodeficiency Virus (HIV) Prevention (CAG-00464N) on CMS.gov for more information.
The Centers for Medicare and Medicaid Services (CMS) has released a National Coverage Decision (NCD) describing the circumstances under which a Seat Elevation Systems as an Accessory to Power Wheelchairs will be covered. CMS defines power seat elevation equipment as equipment that, when used with a power wheelchair, "raises and lowers users while they remain in the seated position. This equipment uses an electromechanical lift system to provide varying amounts of vertical seat to floor height. It does not change the seated angles or the seat's angle relative to the ground."
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:
- 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,
- At least one of the following apply:
- 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,
- 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,
- 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.
The Durable Medical Equipment Medicare Administrative Contractor (DME MAC) has discretion to determine reasonable and necessary coverage of power seat elevation equipment for individuals who use Medicare covered power wheelchairs other than complex rehabilitative power-driven wheelchairs.
Visit Seat Elevation Systems as an Accessory to Power Wheelchairs (CAG-00461N) on CMS.gov for more information.
The National Coverage Decision (NCD) for Home Use of Oxygen has been revised to allow initial coverage for patients with certain conditions to be limited to the shorter of 90 days or the number of days the physician or practitioner has prescribed. Oxygen coverage may be renewed if deemed medically necessary. (Posted July 8, 2022)
Visit Home Use of Oxygen (CAG-00296R3) on CMS.gov for more information.
The Centers for Medicare & Medicaid Services (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: (effective January 21, 2020)
- 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 may furnish acupuncture in accordance with applicable state requirements. Physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel may furnish acupuncture if they meet all applicable requirements and have:
- A masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and
- A current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia.
Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist.
Visit Acupuncture for Chronic Lower Back Pain (cLBP) on CMS.gov for more information.
The Centers for Medicare and Medicaid Services (CMS) released a national policy for coverage of aducanumab (brand name Aduhelm™) and any future medications that are considered monoclonal antibodies that work by decreasing amyloid (an irregular protein in the body) that are approved by the Food and Drug Administration (FDA) for the treatment of Alzheimer's disease (brain condition that cause problems with memory).
Coverage is limited to patients who have a diagnosis of mild cognitive impairment or dementia (memory loss) due to Alzheimer's disease, with presence of amyloid (an irregular protein) in the brain. In addition, coverage will only be provided when treatment is given within an FDA approved clinical trial, a CMS approved study, or a study supported by the National Institutes of Health (NIH). Visit Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease on CMS.gov for more information.
The National Coverage Decision (NCD) for Cochlear Implants is being modified to expand coverage by broadening the patient criteria for inclusion in coverage. Cochlear implantation may be covered for treatment of bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals who demonstrate limited benefit from amplification (defined as test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence cognition).
The following criteria (all) must still be met:
- Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit from appropriate hearing (or vibrotactile) aids;
- Cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation;
- Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, and freedom from lesions in the auditory nerve and acoustic areas of the central nervous system;
- No contraindications to surgery;
- The device must be used in accordance with Food and Drug Administration (FDA)-approved labeling.
CMS may also provide coverage of cochlear implants for beneficiaries not meeting the coverage criteria listed above when performed in the context of FDA-approved category B investigational device exemption clinical trials as defined at 42 CFR 405.201 or as a routine cost in clinical trials under section 310.1 of the National Coverage Determinations Manual titled Routine Costs in Clinical Trials.
CMS has REMOVED the requirement that cochlear implantation may be covered only if the provider is participating in and patients are enrolled in either an FDA-approved category B Investigational Device Exemption clinical trial, a trial under the CMS Clinical Trial Policy, or a prospective, controlled comparative trial approved by CMS for those with hearing test scores of > 40% and ≤ 60%.
Visit National Coverage Determination (NCD) for Cochlear Implantation (NCD 50.3) on CMS.gov for more information.
Want to learn more about your options?
Request FREE Information
Make an appointment
Attend a Medicare seminar
