National Coverage Determinations

If CMS (Medicare) makes a change to your covered services, we will list it here.

 

Supervised Exercise Therapy (SET) 05/25/2017

Consistent with Medicare guidelines, supervised exercise therapy (SET) is covered for beneficiaries with intermittent claudication for the treatment of symptomatic peripheral artery disease. This treatment will apply to the outpatient physical therapy benefit, please see your Evidence of Coverage for more details. Specific treatment requirements must be met to qualify for coverage.

 

Hepatitis B Virus Screening 09/28/2016

Consistent with Medicare guidelines, screening for Hepatitis B Virus (HBV) is covered when ordered by a primary care physician or practitioner within the context of a primary care setting. In addition to existing guidelines for pregnant women, screening for HBV will be covered for asymptomatic, non-pregnant adolescents and adults at high risk for HBV infection (as defined by CMS). CMS has determined that repeated screening would be appropriate annually only for beneficiaries with continued high risk who do not receive a hepatitis B vaccination.

 

Percutaneous Left Atrial Appendage Closure (LAAC) 02/08/2016

Consistent with Medicare guidelines, percutaneous LAAC will be covered when furnished in patients with Non-Valvular Atrial Fibrillation (NVAF) through Coverage with Evidence Development and according to an FDA approved indication for percutaneous LAAC with an FDA approved device. Specific condition requirements must be met for coverage.

 

Hematopoietic Stem Cell Transplantation 01/27/2016

Consistent with Medicare guidelines, allogenic hematopoietic stem cell transplantation (HSCT) for the treatment of Multiple Myeloma, Myelofibrosis, and Sickle Cell Disease is only covered by SelectHealth Advantage if provided as part of a Medicare-approved clinical study meeting specific criteria under Coverage with Evidence Development (CED).

 

HPV Testing 07/09/2015

Consistent with Medicare guidelines, HPV testing will be covered in conjunction with the Pap smear test every 5 years for women aged 30 to 65 years with no cost-share for that testing.

 

HIV Testing 04/13/2015

Consistent with Medicare guidelines, HIV testing will be covered annually for all individuals between the ages of 15 and 65 years, and HIV testing will be covered three times while pregnant, with no cost-share for this testing.

 

Colorectal Cancer Screening Test 10/9/2014

SelectHealth Advantage will cover the Cologuard™ test for colorectal cancer screening once every three years for plan members that meet specific criteria.

 

Screening for Hepatitis C Virus (HCV) in Adults 6/2/2014

SelectHealth Advantage will cover a screening test for Hepatitis C Virus (HCV) under the preventive benefit when ordered by a primary care provider in a primary care setting and performed by a contracted lab when:

  1. The beneficiary is an adult at high risk for HCV infection. (“High risk” means a person with current or past history of illicit injection drug use or received a blood transfusion prior to 1992.) Repeat screening for high risk persons is covered annually only for persons who have had continued illicit injection drug use since the prior negative screening test.

  2. A single screening test is covered for adults who do not meet “high risk” as defined above, but who were born from 1945 through 1965.

 

Transsexual Surgery 5/30/2014

The Centers for Medicare and Medicaid Services (CMS) has determined that Transsexual surgery is now a covered procedure, subject to medical necessity. Prior authorization is required by SelectHealth.

 

Cardiac Rehabilitation Services 2/18/2014

CMS has determined that cardiac rehabilitation services will be covered under the usual benefit level for beneficiaries with stable, chronic heart failure. This is defined as patients who:

  1. Have NOT had recent (≤6 weeks) or planned (≤6 months) major cardiovascular hospitalizations or procedures;
  2. Have left ventricular ejection fraction of 35% or less; AND
  3. Have New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks.

 

Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET)
for Solid Tumors 6/11/2013

Consistent with Original Medicare policy, SelectHealth Advantage will cover three FDG-PET scans (Fluorodeoxyglucose Positron Emission Tomography scans), subject to prior authorization, when used to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy for the same cancer diagnosis. Coverage of any additional PET scans (that is, beyond three) used to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy for the same diagnosis will be determined by SelectHealth as an exception after a case-by-case review.

 

β-amyloid Positron Emission Tomography (PET) in Dementia
and Neurodegenerative Disease 9/27/2013

Consistent with Original Medicare policy, SelectHealth Advantage will cover three FDG-PET scans (Fluorodeoxyglucose Positron Emission Tomography scans), subject to prior authorization, when used to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy for the same cancer diagnosis. Coverage of any additional PET scans (that is, beyond three) used to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy for the same diagnosis will be determined by SelectHealth as an exception after a case-by-case review.

 

Bariatric Surgery for Treatment of Co-Morbid Conditions
Related to Morbid Obesity 9/24/2013

CMS has removed the requirement for bariatric surgery (weight loss surgery) that it must be performed at facilities that are: (1) certified by the American College of Surgeons (ACS) as a Level 1 Bariatric Surgery Center or (2) certified by the American Society for Bariatric Surgery (ASBS) as a Bariatric Surgery Center of Excellence (BSCOE).

 

Autologous Platelet-Rich Plasma (PRP) for Chronic
Non-Healing Wounds 1/1/2013

For enrollees with chronic non-healing diabetic wounds and who are enrolled in a clinical research study that meets specific requirements, platelet-rich plasma (PRP) therapy will be covered if the purpose of the research study is to assess the effectiveness of PRP and it is approved by SelectHealth Advantage.

 

Bariatric Surgery for the Treatment of Morbid Obesity 1/1/2013

For enrollees who meet guidelines for bariatric (weight loss) surgery, Laparoscopic Sleeve Gastrectomy is now a covered surgery.