Knowledge Base Article

This month the focus is on national news instead of the local news. But this national news is not from one of the major television networks, such as NBC, CBS, ABC, or even FOX. It comes to you from the studios of CMS. In February, CMS manualized four National Coverage Determinations (NCDs) ranging from PETs and pacemakers to oral anti-emetics. These NCDs have different effective dates, but all are set for implementation on July 7, 2014.

Pacemaker NCD

The Pacemaker NCD removes the differential coverage requirements for single versus dual chamber pacemakers. Under the revised policy, both single chamber and dual chamber implanted permanent cardiac pacemakers are covered for the same indication - treatment of non-reversible symptomatic bradycardia due to sinus node dysfunction and second and/or third degree atrioventricular block. Symptoms of bradycardia are symptoms that can be directly attributable to a heart rate less than 60 beats per minute (for example: syncope, seizures, congestive heart failure, dizziness, or confusion). The effective date of the policy is August 13, 2013. See MLN Matters Article MM8525 for more information including non-covered indications, affected CPT codes, specific diagnosis codes required for coverage, and billing instructions. Of particular note is the requirement to include a KX modifier on the claim line(s) as an attestation by the provider that documentation is on file verifying the patient has non-reversible symptomatic bradycardia.

PET Aβ for Alzheimer’s Disease

Effective with dates of service on and after September 27, 2013 CMS will cover beta amyloid PET scans (PET Aβ) through coverage with evidence development (CED) during a clinical trial to:

1. develop better treatments or prevention strategies for Alzheimer’s Disease (AD), or, as a strategy to identify subpopulations at risk for developing AD, or
2. resolve clinically difficult differential diagnoses (e.g., frontotemporal dementia

Claims for PET Aβ imaging, through CED during a clinical trial, must contain the following:

• Condition code 30, (for institutional claims only);
• Modifier Q0 and/or modifier Q1 as appropriate;
• ICD-9 dx code V70.7 / ICD-10 dx code Z00.6 (on either the primary/secondary position);
• A PET HCPCS code 78811 or 78814;
• A covered diagnosis code; and
• Aβ HCPCS code A9586 or A9599.

Coverage of PET Aβ is limited to one scan in a patient’s lifetime. See MLN Matters Article MM8526 for more information and a list of the covered diagnosis codes.

FDG PET for Solid Tumors

The second NCD addressing PET scans, effective June 11, 2013, revises the coverage of FDG PET scans for solid tumors to remove the requirement for coverage with evidence development (CED). Providers will no longer have to report data to the National Oncologic PET Registry (NOPR) for FDG PET or FDG PET/CT. Also these claims will no longer require the elements indicating CED: modifier Q0, condition code 30 or diagnosis V70.7. See MMP July Article "Changes to PET Coverage"for a coverage table by cancer type.

Modifiers PI and PS, indicating initial or subsequent treatment strategy are still required.  The NCD allows coverage of three subsequent treatment strategy PET scans after an initial treatment strategy PET. Coverage of any additional FDG 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 the local MACs. Cahaba GBA has indicated that they do not currently have a policy capping the allowed number of FDG PET scans beyond three. They stated that providers should rely on the medical judgment of the clinicians and ensure that documentation clearly supports the need for any additional scans. Providers not within Cahaba’s jurisdiction should check with their local MAC for guidance.

Billing instructions in MLN Matters Article MM8468 explain that:

• a KX modifier is required for subsequent treatment strategy FDG PET scans exceeding three (claims for fourth or more oncologic FDG PET for same diagnosis)
• claims with subsequent treatment strategy (-PS) oncologic FDG PET scans without an initial treatment strategy (-PI) claim present in claims history will be denied (Exception: prostate cancer does not require initial since it is non-covered).
• Alemtuzumab (J9010);

Aprepitant for Chemotherapy Induced Emesis

The final NCD manualized in February concerns aprepitant for chemotherapy induced emesis. Since 2005, Medicare has covered the use of the oral three-drug regimen of aprepitant, a 5HT3 antagonist, and dexamethasone for patients who are receiving certain highly emetogenic chemotherapeutic agents when the antiemetic therapy fully replaces an IV antiemetic. Effective for services on or after May 29, 2013, the following anticancer chemotherapeutic agents have been added to the list of anticancer chemotherapeutic agents for which the use of the oral antiemetic 3-drug combination of oral aprepitant, an oral 5HT3 antagonist, and oral dexamethasone is deemed reasonable and necessary:

• Azacitidine (J9025);
• Bendamustine (J9033);
• Carboplatin (J9045);
• Clofarabine (J9027);
• Cytarabine (J9098, J9100, J9110);
• Daunorubicin (J9150, J9151);
• Idarubicin (J9211);
• Ifosfamide (J9208);
• Irinotecan (J9206); and
• Oxaliplatin (J9263)

MLN Matters Article MM8418 contains all the details including a complete list of all chemotherapeutic agents.

Now the local news – Cahaba did not have any coverage updates this month, while Novitas (both JH and JL) continues to be prolific with new and revised policies and Palmetto has some updates. See the links below for the local coverage updates for your region.

Novitas JH Coverage Updates

February 27, 2014

The following JH MAC LCD has been revised to reflect the Annual CPT/HCPCS Code updates effective for dates of service on and after January 1, 2014 and has also been revised due to a reconsideration request:

Nerve Conduction Studies and Electromyography (L32723)

The following JH MAC LCD has been revised:

Pain Management (L32702)

February 6, 2014

The following JH MAC Local Coverage Determinations (LCDs) have been posted for notice. They will become effective March 27, 2014:

Bariatric Surgical Management of Morbid Obesity (L32619)

Frequency of Dialysis (L32755)

Infrared Photocoagulation (IRC) of Hemorrhoids (L34350)

Intraoperative Neurophysiological Testing (L32605)

Outpatient Sleep Studies (L32711)

Qualitative Drug Testing (L34352)

Surgery: Blepharoplasty (L32715)

Vascular Access for Hemodialysis (L32708)

Wound Care and Cellular and/or Tissue-Based Products for Wounds (CTPs) (L32687) (formerly titled Wound Care and Bioengineered Skin Substitutes)

Comments Received and Contractor Responses

Hemophilia Factor Products (L32735)

The following JH MAC LCDs have been revised to create uniform LCDs with the corresponding Novitas Solutions JL MAC LCDs. The following LCDS will also become effective March 27, 2014:

Cataract Extraction (including Complex Cataract Surgery) (L32690)

Glaucoma Treatment with Aqueous Drainage Device (L32733)

Lacrimal Punctum Plugs (L32607)

Wireless Capsule Endoscopy (L32686)

Novitas JL Coverage Updates

February 27, 2014

The following JL MAC LCD has been revised to reflect the Annual CPT/HCPCS Code updates effective for dates of service on and after January 1, 2014 and has also been revised due to a reconsideration request:

Nerve Conduction Studies and Electromyography (L29547)

February 6, 2014

The following JL MAC Local Coverage Determinations (LCDs) have been posted for notice. They will become effective March 27, 2014:

Cataract Extraction (including Complex Cataract Surgery) (L34344)

Frequency of Dialysis (L34388)

Glaucoma Treatment with Aqueous Drainage Device (L34355)

Intraoperative Neurophysiological Testing (L27499)

Lacrimal Punctum Plugs (L34358)

Outpatient Sleep Studies (L27530)

Surgery: Blepharoplasty (L34396)

Vascular Access for Hemodialysis (L32465)

Wireless Capsule Endoscopy (L34342)

Wound Care and Cellular and/or Tissue-Based Products for Wounds (CTPs) (L27547) (formerly titled Wound Care and Bioengineered Skin Substitutes)

Comments Received and Contractor Responses

Hemophilia Factor Products (L33658)

The following JL MAC LCDs have been revised to create uniform LCDs with the corresponding Novitas Solutions JH MAC LCDs.  The following LCDS will also become effective March 27, 2014:

Bariatric Surgical Management of Morbid Obesity (L34495)

Qualitative Drug Testing (L32050)

Palmetto J11 Coverage Updates

Polices and articles can be viewed on the Medicare Coverage Database by entering the policy number in the Document ID search.

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.