Your source for updates to Medicare-covered services

The Centers for Medicare & Medicaid Services (CMS) makes changes to the services that are covered by Medicare. These changes are updated via National Coverage Determinations.

CMS has issued the following national coverage determinations (NCD):

Effective Dec. 1, 2020: CMS notified their Medicare Administrative Contractors (MACs) that they will cover ventricular assist devices (VADs) under certain conditions and criteria

VADs, or left ventricular assist devices (LVADs), are mechanical blood pumps that are surgically attached to 1 or both intact ventricles of a damaged or weakened heart to assist in pumping blood. Section 20.9.1 of the Medicare NCD Manual established conditions of coverage for VADs.

An NCD that expands coverage is also binding on a Medicare Advantage organization.

VADs and LVADs are covered if they are FDA approved for short-term (e.g., bridge-to-recovery and bridge-to-transplant) or long-term (e.g., destination therapy) mechanical circulatory support for heart failure patients who meet the following criteria:

  • Have New York Heart Association (NYHA) Class IV heart failure
  • Have a left ventricular ejection fraction (LVEF) equal to or less than 25%
  • Are inotrope dependent or have a cardiac index (CI) of 2.2 L/min/m2 while not on inotropes

The patient must also meet 1 of the following conditions:

  • Is on optimal medical management (OMM), based on current heart failure practice guidelines for at least 45 out of the last 60 days and is failing to respond
  • Have advanced heart failure for at least 14 days and is dependent on an intra‐aortic balloon pump (IABP) or similar temporary mechanical circulatory support for at least 7 days

Beneficiaries receiving a VAD or LVAD must be managed by a team of medical professionals based at the facility and the team must include individuals with experience working with patients before and after placement of a VAD or LVAD.

The team must include:

  • At least 1 physician with cardiothoracic surgery privileges and individual experience implanting at least 10 durable, intracorporeal LVADs over the course of the previous 36 months with activity in the last year
  • At least 1 cardiologist trained in advanced heart failure with clinical competence in medical- and device-based management including VADs, and clinical competence in the management of patients before and after placement of a VAD
  • A VAD program coordinator
  • A social worker
  • A palliative care specialist

CMS posted on the CMS website its process for organizations to apply for CMS approval to be designated as a credentialing organization for VAD facilities and a list of approved credentialing organizations, approved standard versions and credentialed facilities.

Effective Jan. 19, 2021: CMS has issued an NCD for screening for colorectal cancer

For services performed on or after Jan. 19, 2021, CMS has determined that a blood-based biomarker test is an appropriate colorectal cancer screening test once every 3 years for Medicare beneficiaries when it is:

  • Performed in a Clinical Laboratory Improvement Act (CLIA)-certified laboratory
  • Ordered by a treating physician

Additionally, all of the requirements below must be met.

The patient is:

  • Age 50–85 years
  • Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test)
  • At average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer or inflammatory bowel disease, including Crohn’s disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer)

The blood-based biomarker screening test must have all of the following:

  • FDA market authorization with an indication for colorectal cancer screening
  • Proven test performance characteristics for a blood-based screening test with both sensitivity greater than or equal to 74% and specificity greater than or equal to 90% in the detection of colorectal cancer compared to the recognized standard (accepted as colonoscopy at this time), based on the pivotal studies included in the FDA labeling

Effective Jan. 19, 2021, CMS issued a reconsideration of a previous NCD expanding coverage of mitral valve Transcatheter Edge-to-Edge Repair (TEER) procedures

This NCD is for mitral valve TEER procedures treating functional mitral regurgitation (MR) and maintained coverage of TEER for treating degenerative MR through coverage with evidence development (CED) and with mandatory registry participation.

Specifically, CMS covers TEER of the mitral valve under CED for treating symptomatic, moderate-to-severe or severe functional MR. This is covered when the patient remains symptomatic despite stable doses of maximally tolerated guideline-directed medical therapy (GDMT) plus cardiac resynchronization therapy, if appropriate. CMS may also cover TEER for treating significant symptomatic degenerative MR when furnished according to an FDA-approved indication. The NCD also includes hospital infrastructure and procedural volume requirements as well as operate procedural volume requirements.

Effective Apr. 13, 2021, CMS issued an NCD for autologous platelet-rich plasma (PRP) for the treatment of chronic non-healing diabetic wounds under specific conditions

Effective for claims with dates of service on and after Apr. 13, 2021, CMS will cover autologous PRP for treating chronic non-healing diabetic wounds for a duration of 20 weeks. The autologous PRP used for treatment must be prepared by devices whose FDA-cleared indications include the management of exuding cutaneous wounds such as diabetic ulcers.

Coverage of autologous PRP for the treatment of chronic non-healing diabetic wounds beyond 20 weeks will be determined by local MACs. Coverage of autologous PRP for the treatment of all other chronic non-healing wounds will be determined by local MACs.

CMS announces removal of 2 national coverage determinations (NCDs), Feb. 18, 2022 update

Effective Date: Jan. 1, 2022: The purpose of this Omnibus change request is to make Medicare contractors aware of the updates to remove 2 National Determination NCDs.

The following 2 NCDs are being removed from the NCD Manual:

  • NCD 180.2 Enteral/Parenteral Nutritional Therapy
  • NCD 220.6 Positron Emission Tomography (PET) Scans

Coverage of the above 2 NCDs revert to MAC discretion effective for claims with dates of service on and after Jan. 1, 2022.

CMS is expanding the eligibility criteria for Medicare beneficiaries receiving low dose computed tomography (LDCT), March 2, 2022 update

Effective Feb. 10, 2022: The Centers for Medicare & Medicaid Services (CMS) announced a final decision for a national coverage determination (NCD) titled Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R), which expands coverage for lung cancer screening with low dose computed tomography (LDCT) to improve health outcomes for people with lung cancer.

Medicare beneficiaries may receive low dose computed tomography (LDCT) when the following criteria are met:

  • Age 50–77 years
  • Asymptomatic (no signs or symptoms of lung cancer)
  • Tobacco smoking history of at least 20 pack-years (1 pack-year = smoking 1 pack per day for 1 year; 1 pack = 20 cigarettes)
  • Current smoker or one who has quit smoking within the last 15 years
  • Received an order for lung cancer screening with LDCT

This final decision:

  • Simplifies requirements for the counseling and shared decision-making visit
  • Removes the requirement for the reading radiologist to document participation in continuing medical education

CMS added a requirement back to the NCD criteria for radiology imaging facilities to use a standardized lung nodule identification, classification and reporting system.

Effective April 7, 2022: CMS approved use of monoclonal antibodies directed against amyloid for the treatment of Alzheimer’s disease under certain coverage criteria

The Centers for Medicare & Medicaid Services (CMS) approved monoclonal antibodies directed against amyloid for the treatment of Alzheimer’s disease (AD) when furnished in accordance with Section B (coverage criteria) under coverage with evidence development (CED) for patients who have:

  • A clinical diagnosis of mild cognitive impairment (MCI) due to AD or mild AD dementia, both with confirmed presence of amyloid beta pathology consistent with AD.

ICD-10 and other coding revisions to NCDs

Effective May 17, 2021: CMS provided a maintenance update to the ICD-10 conversions and other coding updates specific to NCDs

Transmittal 10624 was rescinded and replaced by Transmittal 10804 to make several changes to Business Requirement (BR) 12124.2 and NCD 90.2 Next Generation Sequencing (NGS).

Those changes are:

  • Retain previously deleted codes for 1 year, and then delete following provider education
  • Add 3 current procedural terminology codes and corresponding ICD-10 diagnosis codes
  • Add 1 ICD-10 diagnosis code
  • Delete 12 expired ICD-10 diagnosis codes

This correction also adds BR 12124.2.1 and revised the NCD 90.02 NGS spreadsheet. All other information remains the same.

Effective Jun. 2, 2021: CMS provided a maintenance update to the ICD-10 conversions and other coding updates specific to NCDs

For this update, Transmittal 10804 was rescinded and replaced by Transmittal 10832 to modify the spreadsheets for NCD 90.2, Next Generation Sequencing, and 230.9, Cryosurgery of Prostate.

NCD spreadsheets are located at the CMS website.

Effective Sept. 28, 2021: Transmittal 10963, dated Aug. 19, 2021, is being rescinded and replaced with Transmittal 11025

The changes in this update are:

  • Revise spreadsheet 110.23, Stem Cell Transplants, to add back 30 diagnosis codes to the diagnosis tab removed in error
  • Add override notes to BR 12399.2, NCD 110.23, Stem Cell Transplants, and 12399.5.1, NCD 160.18 VNS
  • Add updated coding to BR 12399.3, NCD 110.24, CAR-T, and its associated spreadsheet, and update BRs 5 and 5.1, NCD 160.18, VNS, and its associated spreadsheet, to reflect accurate code edits

All other information remains the same.

Blood-derived products for chronic, non-healing wounds, Nov. 10, 2021 update

Effective Nov. 10, 2021: Transmittal 10981, dated Sept. 8, 2021, is being rescinded and replaced with Transmittal 11119

The changes in this update are:

  • Change Business BR 12403-04.2, BR 12403 – 04.2.1 and BR 12403 – 04.2.2 to deny
  • Revise BR 12403 – 04.4.2.2 messaging
  • Add BR 12403 – 042.2.1
  • Remove Part A from BR 12403 -04.3 and BR 12403 – 04.3.1
  • Revises verbiage in BR 12403 – 04.5 and extends the implementation date

This correction does not make any revisions to the companion publication 100-03. All revisions are associated with publication 100-04. All other information remains the same.

Effective Jan. 1, 2022, unless otherwise noted in requirements, CMS has issued a change request (CR) for a maintenance update of ICD-10 conversions and other coding updates specific to NCDs 

CMS would like to clarify that coding (as well as payment) is a separate and distinct area of the Medicare program from coverage policy/criteria.

Blood-derived products for chronic, non-healing wounds, Jan. 12, 2022 update

Effective Jan. 12, 2022, Transmittal 11119, dated Sept. 10, 2021, is being rescinded and replaced with Transmittal 11171

This update adds Healthcare Common Procedure Coding System (HCPCS) code G0465 to the instructions and to include additional information on HCPCS cod G0460. This correction:

  • Modifies the IOM attachment for publication 100-04
  • Updates the background section for publication 100-04 and BR 12403-04.1 through 12403 – 04.2.2
  • Updates BR 12403- 04.3 through 12403 – 04.6

This correction does not make any revisions to the companion publication 100-03. All revisions are associated with publication 100-04. All other information remains the same.

Blood-derived products for chronic, non-healing wounds, Jan. 20, 2022 update

Effective Jan. 20, 2022, Transmittal 11171 is being rescinded and replaced with Transmittal 11214. This update:

  • Provides clarification to the note in the Claims Processing business instructions, Pub.100-04, business requirement 12403.04-01
  • Updates the title for the NCD 270.3 Blood Derived Products for Chronic Non-healing Wounds attachment

This correction does not make any revisions to the companion publication 100-03. All revisions are associated with publication 100-04. All other information remains the same.

Effective April 2022, CMS has provided a maintenance update to the ICD-10 conversions and other coding updates specific to NCDs

These NCD coding changes result from newly available codes, coding revisions to NCDs released separately or coding feedback received.

CMS clarifies that coding (as well as payment) is a separate and distinct area of the Medicare program from coverage policy/criteria.

Effective April 2022: change request rescinding and replacing Transmittal 11068.

Transmittal 11068, dated Oct. 21, 2021, is being rescinded and replaced by Transmittal 11179, dated Jan. 12, 2022. This update adds business requirement 12480.10.1 to the attachment for NCD 110.24, chimeric antigen receptor therapy (CAR-T). Also, the update adds generic, unspecified procedure codes to clarify coverage and claims processing in the policy section and review the implementation date. All other information remains the same.

Effective July 1, 2022: CMS transmittal—ICD-10 revision and other coding revisions to NCDs

CMS has provided a maintenance update to the ICD-10 conversions and other coding updates specific to NCDs. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately or coding feedback received.

These revisions include updates to these procedures:

  • 20.4 Implantable Automatic Defibrillators
  • 20.9.1 Ventricular Assist Devices (VADs)
  • 20.31 Intensive Cardiac Rehabilitation
  • 20.31.1 ICR Pritikin Program
  • 20.31.2 ICR Ornish Program
  • 20.31.3 ICR Benson Henry
  • 30.3.3 Acupuncture for Chronic Low Back Pain (cLBP)
  • 110.18 Aprepitant
  • 110.23 Stem Cell Transplants
  • 110.24 CAR T-cell Therapy

View the NCD spreadsheets related to these revisions

CMS clarifies that coding (as well as payment) is a separate and distinct area of the Medicare Program from coverage policy/criteria.

These NCD coding changes result from newly available codes, coding revisions to NCDs separately or coding feedback received. Previous NCD coding changes appear in ICD-10 quarterly updates that can be found at the CMS website.

Edits to ICD-10, and other coding updates specific to NCDs, will be included in subsequent quarterly releases as needed. No policy-related changes are included with these updates. Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process. Please use this link for the NCD spreadsheets included with this CR.

CMS notes:

The translations from ICD-9 to ICD-10 are not consistent 1-to-1 matches, nor are all ICD-10 codes appearing in a complete General Equivalence Mappings (GEMs)* guide or other mapping guides appropriate when reviewed against individual NCD policies.

*GEMs is no longer provided by CMS as of Oct. 1, 2019.

CMS provided a maintenance update to the International Code of Diseases, Tenth Revision (ICD-10) conversions and other coding updates specific to National Coverage Determinations (NCDs), April 6, 2022 update

Effective July 1, 2022: CMS has rescinded and replaced Transmittal 11264, dated Feb. 10, 2022 with Transmittal 11342, dated, April 6, 2022 to:

  • revise BR 12606.10 instructions for NCD 110.24
  • BR 12606.2, fix typo in NCD 160.18 spreadsheet ICD-10 G40.384, which should be G40.834
  • revise implementation verbiage (no changes to the actual implementation date)

All other information remains the same.

For NCDs made more than 18 months ago, please visit the Medicare Coverage webpage on CMS.gov that provides:

  1. A listing of all NCDs including both pending and closed coverage determinations
  2. All national coverage analyses (NCAs) and final decision memos
  3. An index of LCDs
  4. Ability for users to subscribe to the CMS Coverage Listserv and receive weekly notifications when national coverage documents are updated, such as NCAs and NCDs. Listserv subscribers also receive special updates, including CMS announcements of new topics opened for national decision, decision memo postings and final technology assessment (TA) report postings
  5. All email coverage updates sorted by year
  6. A searchable NCD database
  7. Staff name and email links for each coverage topic so that interested individuals can send questions and provide feedback