Previously, CMS invited the public’s input concerning any items and services that may be inappropriately used (i.e., underused, overused, or misused) or provide minimal benefit in hospitals, clinics, emergency departments, doctors’ offices, or in other healthcare settings.[1] CMS also expressed interest in public input on items or services that might improve health outcomes and are not currently covered. CMS asked the public to be specific about items and services including surgical procedures, diagnostic tests or procedures, imaging or radiology services, lab tests, or durable medical equipment (such as glucose monitors or wheelchairs); treatments for diseases such as cancer, heart disease, kidney disease or gastrointestinal disease; or procedures such as orthopedic or eye procedures.
We reviewed and evaluated all of the submissions and believe that many of the suggested topics may be suitable candidates for further review. Some of these topics may have the potential to be subjects for further evaluation using literature reviews, claims based analyses, or as subjects for analysis in a National Coverage Determination (NCD). In considering topics for inclusion on our list we assessed our current policies and the availability or absence of evidence based guidelines and other pertinent medical literature. We also weighed their relevance to the scope of the Medicare benefits under Part A and Part B and the NCD authority and the potential impact on the Medicare program and on Medicare beneficiaries. In addition to the publicly submitted topics, we also added three topics of interest to CMS (intraaortic balloon pumps and percutaneous ventricular assist devices, lap-band surgery for obesity and kyphoplasty).
The items and services added by CMS are based on our internal consideration of the medical literature, Medicare claims experience of the MACs, horizon scans of medical literature, and interactions with the stakeholder community at various scientific meetings. Below is the complete list of potential NCD topics. We look forward to continued public dialogue and input regarding CMS coverage policy.
| Item or service |
Current coverage policy |
| Abdominal CT |
No NCD, local coverage policies in place |
| Appeals on behalf of the members by DME companies and vendors, when there is conflict of interest |
The NCD statutory authority is separate from the appeals authority or conflict of interests. |
| Automatic implantable cardiac defibrillators |
NCD/CED |
| Back surgery for recurring low back pain |
NCD for Lumbar Artificial Disc Replacement, no LCDs |
| Conflicting information from vendors and physical therapists evaluations |
We believe this topic is too broad to support the development of an NCD at this time |
| Colorectal cancer screening |
Coverage for all Medicare beneficiaries |
| CT pulmonary angiography for patients with suspected pulmonary embolism |
No NCD, local coverage policies in place |
| Endoscopy for gastroesophageal reflux disease (GERD) |
NCD + LCD guidelines |
| Epidural and transforaminal injections |
No NCD, local coverage policies in place |
| Genetic testing and local coverage decisions |
NCD for genetic testing for warfarin response, LCDs for some specific diseases or conditions |
| Implantable central nervous system stimulators for intractable pain |
NCD - Covers dorsal column (also called spinal cord) and depth (also called deep) brain stimulators; and peripheral nerve stimulators
|
| Knee MRI for likely arthritic condition |
No NCD, local coverage policies in place |
| Lap-band surgery for obesity |
NCD |
| Left ventricular assist devices |
NCD/CED |
| Lung volume reduction surgery |
NCD |
| Misuse and overuse of nonemergent ambulance transports to ERs and dialysis facilities |
Recent LCDs define non emergent use of ambulances. |
| Misuse and overuse of the hospital outpatient settings for IV infusions and injectables |
Covered under revenue codes and under some specific NCDs and LCDs |
| Negative-pressure wound therapy (NPWT) |
No NCD, local coverage policies in place |
| Neuroimaging for headaches |
No NCD, local coverage policies in place |
| Nonemergent percutaneous transluminal coronary angioplasty (PTCA) and stents |
NCD |
| Nuclear stress tests for cardiac related symptoms |
No NCD, local coverage policies in place |
| Intraaortic balloon pump and percutaneous ventricular assist device for cardiogenic shock, high risk PCI and acute MI |
No NCD, local coverage policies in place |
| Physical/occupational/speech therapy in outpatient settings including long term care facilities |
No NCD, local coverage policies in place |
| Positron emission tomography (PET) scan for Alzheimer’s Disease |
NCD/CED |
| Power wheelchairs (vendors misrepresenting the facts, unskilled physical therapists and physician lack of knowledge regarding criteria) |
NCD |
| Prostate-specific antigen (PSA) -based screening |
Covered under statute |
| Proton beam therapy for prostate cancer |
No NCD, local coverage policies in place |
| Surgery for low risk prostate cancers |
No NCD or LCD |
| Underuse of physical therapy and other non-invasive therapy for back pain |
LCDs provide guidelines for physical therapy, multiple LCDs on noninvasive treatments. |
| Vertebroplasty and kyphoplasty |
No NCD, local coverage policies in place |
| Whole genome profiling |
No NCD or LCD |
| Wound center debridement vs. active wound management and frequent non-medically necessary debridement for very small wounds |
LCDs provide guidelines for wound debridement |
