Question

300 Setion S COMPLANCE CASE 5-15 National Coverage Determination CAS You are a campliance ccordnator. Part of your job is to assist the admisians cienk in will covwr services erdered or t an ideanted beraliciary notice needs to be given Yau are d er the admission clerks tn cross-relarence when admitting patients To accomplish this explain the NCD. NCDs can be found onine at hittp:/fwww.ems.ths gox: You can alsa 5ndad n the web lines section &f the student companion webste. Table 5-5 is avalable on the uden watnaite for your use. on the wsn es l NCD Does Medicare Identify Any Procedure? Limitations Yes/No Coverage Procedure Vagus nerve stimulation Lipid testing Cytogenetic studies Date Secsan Bariatric surgery for treatment of morbid obesty Acupurcture FDG PET for melanoma Pancreas transplant Mammogram Refractive keratoplasty Endothelial cell photography

I need the National Coverage Determination (NCD) for the entire New York state.

Answer 1

1. Vagus nerve stimulation :

National Coverage Determination (NCD) allowing coverage of VNS for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed.

Limitation - VNS is not reasonable and necessary for all other types of seizure disorders which are medically refractory and for whom surgery is not recommended or for whom surgery has failed. VNS is not reasonable and necessary for resistant depression.

Implementation date - 11/14/2018

NCD ID - NCD160.18

2. Lipid testing :

Indications and Limitations of Coverage :-

Conditions in which lipid testing may be indicated include:

Assessment of patients with atherosclerotic cardiovascular disease.

Evaluation of primary dyslipidemia.

Any form of atherosclerotic disease, or any disease leading to the formation of atherosclerotic disease.

Diagnostic evaluation of diseases associated with altered lipid metabolism, such as: nephrotic syndrome, pancreatitis, hepatic disease, and hypo and hyperthyroidism.

Secondary dyslipidemia, including diabetes mellitus, disorders of gastrointestinal absorption, chronic renal failure.

Signs or symptoms of dyslipidemias, such as skin lesions.

As follow-up to the initial screen for coronary heart disease (total cholesterol + HDL cholesterol) when total cholesterol is determined to be high (>240 mg/dL), or borderline-high (200-240 mg/dL) plus two or more coronary heart disease risk factors, or an HDL cholesterol, <35 mg/dl.

To monitor the progress of patients on anti-lipid dietary management and pharmacologic therapy for the treatment of elevated blood lipid disorders, total cholesterol, HDL cholesterol and LDL cholesterol may be used. Triglycerides may be obtained if this lipid fraction is also elevated or if the patient is put on drugs (for example, thiazide diuretics, beta blockers, estrogens, glucocorticoids, and tamoxifen) which may raise the triglyceride level.

When monitoring long term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia.

Any one component of the panel or a measured LDL may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.

Limitations

Lipid panel and hepatic panel testing may be used for patients with severe psoriasis which has not responded to conventional therapy and for which the retinoid etretinate has been prescribed and who have developed hyperlipidemia or hepatic toxicity. Specific examples include erythrodermia and generalized pustular type and psoriasis associated with arthritis.

Routine screening and prophylactic testing for lipid disorder are not covered by Medicare. While lipid screening may be medically appropriate, Medicare by statute does not pay for it. Lipid testing in asymptomatic individuals is considered to be screening regardless of the presence of other risk factors such as family history, tobacco use, etc.

Once a diagnosis is established, one or several specific tests are usually adequate for monitoring the course of the disease. Less specific diagnoses (for example, other chest pain) alone do not support medical necessity of these tests.

When monitoring long term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it is reasonable to perform the lipid panel annually. A lipid panel at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia.

Any one component of the panel or a measured LDL may be medically necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.

Implementation date - 3/11/ 2005

NCD ID - NCD 190.23

3. Cytogenetics studies :

Indications and limitations :-

Medicare covers these tests when they are reasonable and necessary for the diagnosis or treatment of the following conditions:  Genetic disorders (e.g., mongolism) in a fetus;  Failure of sexual development;  Chronic myelogenous leukemia;  Acute leukemias lymphoid (FAB L1-L3), myeloid (FAB M0-M7), and unclassified; or  Myelodysplasia .

Implementation date - 1/9/2019

NCD ID - NCD190.3

4. Bariatric surgery for treatment of morbid obesity :

Obesity Coverage Navigation

Medicare coverage

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MEDICARE’S CRITERIA FOR WEIGHT LOSS SURGERY COVERAGE

LAST UPDATED ON : OCTOBER 3, 2017

Medicare covers weight loss surgery in most cases assuming you meet the coverage requirements. Not every weight loss procedure is covered either. If the criteria are met, Medicare covers Gastric Bypass, Lap Bands and Gastric Sleeve surgeries.

MEDICARE PRE-APPROVAL REQUIREMENTS

The following criteria must be met in order for Medicare to cover your weight loss surgery:

BMI (body mass index) of 35 or greater – What’s your BMI?

At least one co-morbidity – This is a serious illness directly related to your obesity.

i.e. sleep apnea, high blood pressure, diabetes, etc.

You must have documented evidence that you’ve been obese for the last 5 years.

Documented participation in a medically supervised weight loss program. Typically, you must show that you have participated and failed more than one program.

A letter from your physician recommending or supporting weight loss surgery.

Passed a psychological evaluation.

All other treatable medical diseases have been ruled out as a possible cause for your obesity. Adrenal, pituitary, or thyroid screening tests have been completed and are normal.

Implementation date - 11/01/2018