National Coverage Determinations

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). The following NCDs have been finalized in the past 12 months.

Implantable Pulmonary artery sensors for heart failure

Effective January 13, 2025: NCD 20.36, CMS advised that effective January 13, 2025, claims shall be paid for implantable pulmonary artery sensors for heart failure management as described in Pub. 100-03, Medicare NCD Manual, Chapter 1, section 20.36. Effective for services performed on or after January 13, 2025, the Centers for Medicare & Medicaid.  Services (CMS) has determined that the evidence is sufficient to cover implantable pulmonary artery pressure sensors (IPAPS) for heart failure (HF) management under Coverage with Evidence Development (CED) when furnished according to a Food and Drug Administration (FDA) market-authorized indication and all of the following conditions are met:

• Patient Criteria
• Physician Criteria
• CED Study Criteria

Reference NCD - Implantable Pulmonary Artery Pressure Sensors for Heart Failure Management (20.36)

Noninvasive Positive Pressure Ventilation (NIPPV) in the Home for the Treatment of Chronic Respiratory Failure (CRF) Consequent to Chronic Obstructive Pulmonary Disease (COPD) 

Effective June 9, 2025 : NCD 240.3, CMS announced coverage for in the home a RAD with backup rate feature to deliver high intensity noninvasive ventilation (NIV) as treatment for patients with chronic respiratory failure (CRF) consequent to chronic obstructive pulmonary disease (COPD). A RAD with backup rate feature is covered in the home for an initial 6-month period for patients with COPD when all the following criteria are met: Patient and Usage Criteria

Reference NCD - Noninvasive Positive Pressure Ventilation (NIPPV) in the Home for the Treatment of Chronic Respiratory Failure (CRF) Consequent to Chronic Obstructive Pulmonary Disease (COPD) (240.9)

Pre-Exposure Prophylaxis (PrEP) for Human Immunodeficiency Virus (HIV) Prevention

Effective 04/07/2025,  Pre-exposure prophylaxis (PrEP) involves the use of antiretroviral drugs to decrease the risk of acquiring human immunodeficiency virus (HIV). Under § 1861(ddd)(1) of the Social Security Act (the Act), the Centers for Medicare & Medicaid Services (CMS) has the authority to add coverage of “additional preventive services” through the Medicare national coverage determination (NCD) process if certain statutory requirements are met: (1) reasonable and necessary for the prevention or early detection of illness or disability, (2) recommended with a grade of A or B by the United States Preventive Services Task Force (USPSTF), and (3) appropriate for individuals entitled to benefits under Part A or enrolled under Part B.

Revision 8/2025-  The purpose of this Change Request (CR) is to provide a maintenance update of ICD-10 coding changes specific to NCDs. (TN 13375 ) (CR14197)

Reference - NCD - Pre-Exposure Prophylaxis (PrEP) for Human Immunodeficiency Virus (HIV) Prevention (210.15)