National Coverage Determinations

The Centers for Medicare & Medicaid Services (CMS) will allow coverage for autologous platelet-rich plasma (PRP) only for the treatment of chronic non-healing diabetic, venous and/or pressure wounds when PRP is provided under a clinical research study that meets specific requirements. In accordance with CMS guidance, Humana will allow for this service when the specified criteria are met.

The Centers for Medicare & Medicaid Services (CMS) will allow coverage of stand-alone Laparoscopic Sleeve Gastrectomy (LSG) for the treatment of co-morbid conditions related to obesity in Medicare beneficiaries when specific conditions are met. In accordance with CMS guidance, Humana will allow for this service when the specified criteria are met.

The Centers for Medicare & Medicaid Services (CMS) will allow coverage for Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Low Back Pain (CLBP) only when the patient is enrolled in an approved clinical study under Coverage with Evidence Development (CED). Claims should be submitted and reimbursed by the Medicare Administrative Contractor.

Transcatheter Aortic Valve Replacement (TAVR) is covered for the treatment of symptomatic aortic valve stenosis when furnished according to a Food and Drug Administration (FDA)-approved indication and when various conditions outlined in the National Coverage Determination (NCD) are met. For indications that are not approved by the FDA, patients must be enrolled in qualifying clinical studies that meet requirements. In accordance with CMS guidance, Humana will allow for this service when the specified criteria are met.

Medicare Administrative Contractors acting within their respective jurisdictions may determine coverage of adult liver transplantation for the following malignancies: (1) extrahepatic unresectable cholangiocarcinoma (CCA); (2) liver metastases due to a neuroendocrine tumor (NET); and, (3) hemangioendothelioma (HAE). In accordance with CMS guidance, Humana will follow the directions of any issued determinations.

Cardiac transplantation is covered under Medicare when performed in a facility which is approved by Medicare as meeting institutional coverage criteria. In accordance with CMS guidance, Humana will allow for this service under the specified criteria.

CMS will cover extracorporeal photopheresis for the treatment of Bronchiolitis Obliterans Syndrome (BOS) following lung allograft transplantation only when extracorporeal photopheresis is provided under a clinical research study that meets specific requirements to assess the effect of extracorporeal photopheresis for the treatment of BOS following lung allograft transplantation. In accordance with CMS guidance, Humana will now allow for this service under the specified conditions.

CMS has determined that screening for obesity in older adults along with high intensity behavioral interventions is reasonable and necessary for the prevention or early detection of illness or disability. In accordance with CMS guidance, Humana will now allow for these preventive services.

CMS has determined that the use of PROVENGE^® for the treatment of asymptomatic or minimally symptomatic metastatic castrate-resistant (hormone refractory) prostate cancer is reasonable and necessary. In accordance with CMS guidance, Humana will now allow the use of PROVENGE^® for Medicare Advantage patients with these diagnoses.

CMS has determined that the evidence is adequate to conclude that magnetic resonance imaging (MRI) improves health outcomes for Medicare beneficiaries with implanted permanent pacemakers (PMs) when the PMs are used according to the FDA-approved labeling for use in an MRI environment. In accordance with CMS guidance, Humana will now allow the use of MRIs for Medicare Advantage patients with permanent pacemakers.

CMS will now cover an annual alcohol misuse screening and up to four, brief face-to-face behavioral counseling visits in a primary care setting to reduce alcohol misuse. In accordance with CMS guidance, Humana will now allow for these preventive services.

CMS will now cover an annual screening up to 15 minutes for Medicare beneficiaries when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. In accordance with CMS guidance, Humana will now allow a screening as a preventive service.

CMS now covers intensive behavioral therapy for cardiovascular disease, inclusive of one face-to-face risk reduction visit annually. In accordance with CMS guidance, Humana will now allow for this preventive service.

The evidence is adequate to conclude that screening for chlamydia, gonorrhea, syphilis and hepatitis B, as well as high intensity behavioral counseling (HIBC) to prevent STIs is reasonable and necessary for the prevention or early detection of an illness or disability. Therefore, CMS will cover screening for these indicated STIs with the appropriate laboratory tests when ordered by the primary care physician or practitioner. In accordance with CMS guidance, Humana will now allow for these preventive services.