National Coverage Determinations

From time-to-time CMS makes changes to the services that are covered by Medicare. These changes are updated via National Coverage Determinations. The information provided below is a summary of the coverage change.

Effective 6/30/2011: Autologous Cellular Immunotherapy Treatment for Prostate Cancer

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, CarePlus will now allow the use of PROVENGE® for Medicare Advantage patients with these diagnoses.

Effective 7/7/2011: Magnetic Resonance Imaging (MRI)

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, CarePlus will now allow the use of MRIs for Medicare Advantage patients with permanent pacemakers.

Effective 10/14/2011: Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse

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, CarePlus will now allow for these preventive services.

Effective 10/14/2011: Screening for Depression in Adults

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, CarePlus will now allow a screening as a preventive service.

Effective 11/8/2011: Intensive Behavioral Therapy for Cardiovascular Disease

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

Effective 11/8/2011: Screening for Sexually Transmitted Infections (STIs) & High Intensity Behavioral Counseling to Prevent STIs

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, CarePlus will now allow for these preventive services.

Effective 11/29/11: Obesity Therapy

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, CarePlus will now allow for these preventive services.