List of National Coverage Determinations
for Contract Year 2012
This a list of benefit changes that impact Medicare Advantage members’ coverage as a result of National Coverage Determinations (NCDs). The NCDs are notices issued by CMS to describe a particular change in Original Medicare coverage that is also applicable to Medicare Advantage coverage. NCDs generally provide information on circumstances in which an item, service, treatment procedure, or technology is considered to be covered (or not covered). This list is only a summary of NCDs; details can be found online in
CMS's Medicare Coverage Database. NCD Title
Decision Effective Implementation Benefit Category
Items/Service Description
Prior Authorization Date
Date
Required?
Intensive
Behavioral
Therapy for
Obesity
11/29/2011
Screening for 11/8/2011
Sexually Transmitted Infections (STIs) and High‐Intensity Behavioral Counseling (HIBC) to Prevent STIs 3/6/2012
Additional
Preventive
Services
Effective for claims with dates of service November 29, 2011, No
and later, Medicare beneficiaries with obesity (BMI ≥ 30
kg/m2), who are competent and alert at the time that
counseling is provided and whose counseling is furnished by a
qualified primary care physician or other primary care
practitioner in a primary care setting are eligible for: One faceto-face visit every week for the first month; One face-to-face
visit every other week for months 2-6; One face-to-face visit
every month for months 7-12, if requirements are met.
2/27/2012
Additional Effective for claims with dates of services on or after November 8, No
Preventive Services 2011, Medicare beneficaries will be covered for screening for United States Preventive Services Task Force (USPSTF)‐indicated STIs (chlamydia, honorrhea, syphilis, hepatitis B) with the appropriate FDA‐approved/cleared laboratory tests, used consistent with FDA‐approved labeling, and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations. In addition, Medicare beneficiaries are covered up to two individual 20‐ to 30‐minute, face‐to‐face counseling sessions annually for HIBC to prevent STIs, for all sexually active adolescents, and for adults at increased risk for STIs. Coverage of HIBC to prevent STIs is consistent with the USPSTF recommendation.
Y0079_5773 Approved 05302012
List of National Coverage Determinations
for Contract Year 2012
NCD Title
Decision Effective Implementation Date
Date
Benefit Category
Extracorporeal Photopheresis
4/30/2012
10/1/2012
Physicians' Services Effective for claims with dates of service on or after April 30, 2012, No
Medicare beneficaries will be covered 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.
8/8/2011 (Update issued 1/6/2012)
Outpatient Hospital Effective for services performed on or after June 30, 2011, Medicare No
Serivces Incident to beneficaries will be covered for the use of autologous cellular a Physician's Service immunotherapy treatment ‐ sipuleucel‐T; PROVENGE, which improves health outcomes for Medicare beneficiaries with and Physicians' asymptomatic or minimally symptomatic metastatic Services
castrateresistant (hormone refractory) prostate cancer, and thus is reasonable and
necessary for this on‐label indication.
Autologous Cellular 6/30/2011
Immunotherapy Treatment
Y0079_5773 Approved 05302012
Items/Service Description
Prior Authorization Required?