Medicare pays for items and services that are
reasonable and necessary for the diagnosis or treatment of an illness or
injury. What Medicare will cover is described in national coverage
determinations (NCD), each one focusing on a specific therapy, procedure, or
National Coverage Determination (NCD)
The Medicare NCD for Stem Cell Transplantation should guide your center in what is covered for your Medicare patients. Although you may find that Medicare sometimes pays for indications outside of the NCD, it is financially risky to assume that this will always happen. Always check the NCD to determine what is covered.
The NCD states that allogeneic transplant is
covered for leukemia, aplastic anemia, severe combined Immunodeficiency disease
(SCID), and Wiskott-Aldrich syndrome. Allogeneic transplant for Myelodysplastic
Syndromes (MDS), myelofibrosis (MF), sickle cell disease (SCD), and multiple
myeloma is covered in the context of a Medicare-approved, prospective clinical
study, which is known as Coverage with Evidence Development (CED). Visit Medicare
Clinical Trials to
learn more about CED.
Regional Coverage Policies
Medicare uses a network of contractors called Medicare
Administrative Contractors (MACs), which are private companies that are
contracted to perform services on behalf of Medicare, such as process claims
and answer provider inquiries. MACs have regional policies, which means that
they may cover indications that are not listed in the NCD. We recommend getting
to know your MAC medical director and working with them if you have coverage
about your MAC (CMS.gov).
MAC Coverage Case Study: NGS
One example of variation in coverage by MAC is for allogeneic HCT for patients with lymphomas.
National Government Services (NGS), which is the MAC for Minnesota, Wisconsin, Illinois, New York, Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont issued a local coverage article (LCA) detailing coverage for allogeneic HCT for multiple lymphoma indications, greatly improving access for Medicare beneficiaries in states within this MAC.
NMDP was successful is advocating for the CGS MAC, which covers Kentucky and Ohio, to agree to issue the same LCA (official implementation is still pending) and is currently working to expand HCT coverage for lymphomas in the Noridian and Palmetto MAC regions.
If you are having difficulties with coverage and would like NMDP to be involved in your center’s advocacy efforts, please email PayerPolicy@NMDP.org.
- View your center’s MAC (CMS.gov)
- NGS LCA for Stem Cell Transplantation (CMS.gov)
LCA Covered Diagnosis Codes - Lymphoma (XLS)
How to Determine Coverage for Medicare Patients
Follow these steps to determine coverage for your Medicare patient.
if your patient has Standard Medicare or Medicare Advantage
Medicare Advantage patients may have additional programs available to them that Standard Medicare patients will not have such as Case Management, and also may have different rules. For example, Standard Medicare does not require prior authorization or notification, but Medicare Advantage plans may require it.
eligibility for all parts of Medicare
Ensure you know what parts of Medicare your patient is covered under. If your patient has Standard Medicare, you can determine eligibility through your MAC. For patients with Medicare Advantage, you will check eligibility with the health plan.
if the patient has Medigap insurance that will cover Medicare co-pays
This will affect how much the patient may need to pay out of pocket.
the NCD carefully
Determine if the indication your patient is being transplanted for is covered according to the list of covered indications. View the NCD (CMS.gov).
the clinical trial NCD
If your patient is on a clinical trial, the clinical trial NCD (CMS.gov) will help you determine what will be covered.
Standard Medicare plans do not support a prior authorization process for medical procedures. What this means is that you won’t know for sure if the procedure is covered until after the care has been delivered. However, Medicare Advantage plans often require prior authorization, and these plans have a standard 14-day period in which to make a coverage authorization decision. If your patient’s health could be seriously harmed by waiting 14 days, ask the plan for a fast decision (within 72 hours).
The prior authorization process for Medicare
Advantage patients will follow the same process used for other products at that
payer. Please refer to our commercial
authorization page for specific details on this process.
- An interactive tool to help you determine Medicare coverage (Medicare.gov)