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 (NCDs).
CMS has issued the following NCDs:
Effective March 6, 2024: National Coverage Determination (NCD) 110.23, Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for Myelodysplastic Syndromes (MDS)
On March 6, 2024, CMS issued a final decision under National Coverage Determination (NCD) 110.23 to expand Medicare coverage for allogeneic hematopoietic stem cell transplant using bone marrow, peripheral blood or umbilical cord blood stem cell products for Medicare patients with MDS who have prognostic risk scores of:
- ≥ 1.5 (Intermediate-2 or high) using the International Prognostic Scoring System (IPSS), or
- ≥ 4.5 (high or very high) using the International Prognostic Scoring System - Revised (IPSS-R), or
- ≥ 0.5 (high or very high) using the Molecular International Prognostic Scoring System (IPSS-M)
Additional instruction may be found in: Publication (Pub) 100-03, NCD Manual, chapter 1, section 110.23, for information regarding this NCD and Pub. 100-04, Claims Processing Manual (CPM), chapter 3, section 90.3.1.
Effective October 11 , 2023: National Coverage Determination (NCD) 20.7 Percutaneous Transluminal Angioplasty (PTA) of the Carotid Artery Concurrent with Stenting
On October 11, 2023, CMS issued an NCD updating coverage under section B4 of NCD 20.7. The updated NCD covers PTA of the carotid artery concurrent with stenting with the placement of an FDA-approved carotid stent with an FDA-approved or cleared embolic protection device, for Medicare beneficiaries with symptomatic carotid artery stenosis ≥50% and asymptomatic carotid artery stenosis ≥70%.
As a result of the revised eligibility criteria for this NCD, CMS is replacing the current text of 20.7 sections B4 and D of the NCD Manual, Publication (Pub.) 100-03, Chapter 1, Part 1, and Chapter 32, Section 160 of the Claims Processing (MCP) Manual, Pub. 100-04.
Effective January 1, 2023: CMS issued a change request to make contractors aware of policy updates resulting from changes specified in the Calendar Year (CY) 2023 Physician Fee Schedule (PFS) Final Rule. The policy updates include removal of one selected National Coverage Determination (NCD): Ambulatory Electroencephalographic (EEG) Monitoring and Expanding Coverage of Colorectal Cancer Screening.
Transmittal 11865 issued February 16, 2023, is being rescinded and replaced by Transmittal 12299, dated October 12, 2023, to provide clarifications on CMS policy and related claims processing instructions for our approach to colonoscopies within the context of a complete colorectal cancer screening by revising the policy section with additional verbiage, adding Business Requirement (BR) 13017 - 04.5.3, and revising BRs 13017-04.1 and 13017 - 04.4 to 13017 - 04.10. This CR is amended to remove the requirement (and corresponding Pub. 100-04 narrative) that contractors shall return to provider/ return as un-processable certain screening colonoscopy claims that do not include the KX modifier. This correction does not make any revisions to the companion Pub. 100-02 or Pub. 100-03; all revisions are associated with Pub. 100-04. All other information remains the same.
Separately, the policy updates also include policies to expand colorectal cancer screening coverage by:
- Reducing the minimum age for certain Colorectal Cancer (CRC) screening tests from 50 to 45 years
- Expanding the regulatory definition of CRC screening tests to include a follow-on screening colonoscopy after a Medicare covered non-invasive stool-based test returns a positive result.
Effective August 17, 2023: CMS issued a memo regarding the Significant Cost Determination for Medicare Coverage of Monoclonal Antibodies for the Treatment of Alzheimer's Disease
CMS has determined that the cost of coverage for monoclonal antibodies that target amyloid (or plaque) for the treatment of Alzheimer's disease under NCD 200.3 does not meet the significant cost threshold. Therefore, MA plans are required to assume the costs and cover anti-amyloid monoclonal antibodies antibody treatments for Alzheimer’s following the coverage criteria set forth under NCD 200.3.
Consistent with procedures under Traditional Medicare, Medicare Advantage plans must collect the applicable registry trial number on each claim or encounter for monoclonal antibodies that receive traditional approval from the FDA.
Effective May 16, 2023: CMS issued a Benefit Category Determination and National Coverage Determination (NCD 280.16) for power seat elevation equipment on certain power wheelchairs.
Effective for claims with dates of service 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 under NCD 280.16:
- 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); 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.
Effective August 4, 2023: CMS has advised of the following policy updates effective for claims with dates of service on and after January 1, 2024
The changes in this update include:
- One initial acupuncture HCPCS (97810 OR 97813) shall be allowed to be reported with or without HCPCS add-on code(s) (97811 AND/OR 97814) on the same date of service (DOS) and this equals one session. Only one initial code HCPCS 97810 OR 97813 can be reported per DOS.
- Dry needling HCPCS 20560 OR 20561 shall be allowed to be reported and this equals one session. Dry needling and acupuncture are disallowed on the same DOS. HCPCS 20560 & 20561 are disallowed on the same DOS as HCPCS 97810, 97811, 97813, or 97814).
- All other existing editing other than the frequency described above that is contained in CRs 11755, 12480, and 12822, remain in effect
Effective July 31, 2023: CMS issued the transmittal 12112 to communicate the proposed technical manual changes that were made to the National Coverage Determination (NCD) Manual, Publication 100-03, Chapter 1 Parts 1, 3, and 4.
The changes in this update include:
- In Chapter 1, Part 1, Section 20.33 Transcatheter Edge-To-Edge (TEER) for Mitral Valve Regurgitation title was corrected to align with the title of the NCD.
- In Chapter 1, Part 1, Section 20.4 Implantable Cardioverter Defibrillators (ICDs), in Part B number 4 added verbiage ‘or cardiac arrest due to VF’ to align with Section I of the Final Decision Memo.
- In Chapter 1, Part 3, Section 190.1 Histocompatibility Testing, removed 4 bullets and replaced them with letters to align with the original Coverage Issues Manual language.
- In Chapter 1, Part 4, Section 280.1, in the DME reference list, the Muscle Stimulator hyperlink is being changed from 250.4 to 160.12 to refer back to the correct section in the manual.
Effective January 1, 2023: CMS issued a change request to make contractors aware of policy updates resulting from changes specified in the Calendar Year (CY) 2023 Physician Fee Schedule (PFS) Final Rule. The policy updates include removal of one selected National Coverage Determination (NCD): Ambulatory Electroencephalographic (EEG) Monitoring.
Date of Transmittal: January 27, 2023
*Unless otherwise specified, the effective date is the date of service.
IMPLEMENTATION DATE: February 27, 2023 - Requirements Implementation Date; April 3, 2023 - For Release Tracking Purposes Only
Separately, the policy updates also include policies to expand colorectal cancer screening coverage by:
- Reducing the minimum age for certain Colorectal Cancer (CRC) screening tests from 50 to 45 years
- Expanding the regulatory definition of CRC screening tests to include a follow-on screening colonoscopy after a Medicare covered non-invasive stool-based test returns a positive result.
NCD Removal:
- CMS finalized a proposal to remove NCD 160.22 EEG Monitoring
CRC Screening:
- The minimum age payment and/or coverage limitation for the following CRC screening tests is now reduced to 45 years of age or older:
- Screening Flexible Sigmoidoscopy Test
- Screening Guaiac-based Fecal Occult Blood Test (gFOBT)
- Screening Immunoassay-based Fecal Occult Blood Test (iFOBT)
- Screening The Cologuard™ – Multi-target Stool DNA (sDNA) Test
- Screening Barium Enema Test
- Screening Blood-based Biomarker Test