Call CommunityCare Senior Health Plan at 1-800-642-8065, TTY/TDD call 1-800-722-0353 for more information and rate quotes.

National Coverage Determination

Below are national coverage determination updates released since January 2017. Click the "view details" button to read more about the determination and what has changed.

Below are national coverage determination updates released since January 2018. Click the "view details" button to read more about the determination and what has changed.

National Coverage Determination Notifications
Posted Coverage Determination Clinical Trial  
3/23/2018Decision Memorandum on Diagnostic Laboratory Tests

Decision Memorandum on Diagnostic Laboratory Tests using Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer (CAG-00450N)

Effective 3/16/2018, CMS has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally, when performed in a CLIA-certified laboratory, when ordered by a treating physician and when certain requirements are met.
YesView Details
6/29/2017Screening for Hepatitis B Virus (HBV) Infection

Transmittal 197 - CMS has determined that effective September 28, 2016, screening for HBV infection will be covered with the appropriate U.S. Food and Drug Administration (FDA) approved/cleared laboratory tests, used consistent with FDA-approved labeling and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations.
NoView Details
4/3/2017Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Oxygen) (CAG-00060R)

The Centers for Medicare & Medicaid Services (CMS) received a reconsideration request to remove the coverage exclusion of Continuous Diffusion of Oxygen Therapy (CDO) from NCD Manual 20.29, Section C.
YesView Details
7/1/2016Stem Cell Transplantation Formerly 110.8.1 (110.23)

Transmittal 191 from 4/29/2016 has been rescinded and replaced by Transmittal 193, dated 7/1/2016 providing clarifying language referring to the Pub. 100-03 NCD manual, under Summary of Changes. No other changes. (TN 193 ) (CR9620)
YesView Details
6/1/2016Hyperbaric Oxygen Therapy (20.29)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
NoView Details
6/1/2016Heart Transplants (260.9)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
NoView Details
6/1/2016Cryosurgery of Prostate (230.9)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
NoView Details
6/1/2016Counseling to Prevent Tobacco Use (210.4.1)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
NoView Details
6/1/2016Colorectal Cancer Screening Tests (210.3)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed.(TN 1672 )
NoView Details
6/1/2016Cochlear Implantation (50.3)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
NoView Details
6/1/2016Percutaneous Transluminal Angioplasty (PTA) (20.7)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
NoView Details
6/1/2016Mammograms (220.4)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
NoView Details
6/1/2016Implantable Automatic Defibrillators (20.4)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
YesView Details
6/1/2016Smoking and Tobacco-Use Cessation Counseling (210.4)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
NoView Details
6/1/2016Aprepitant for Chemotherapy-Induced Emesis (110.18)

Transmittal 1665 from 5/13/2016 has been rescinded and replaced by Transmittal 1672. 1) Remove FISS responsibility and 1st sentence; 2) Procedure codes update; 3) Dx. codes updated; 4) Override capability and contractor discretion verbiage removed. (TN 1672 )
NoView Details
5/1/2016Percutaneous Left Atrial Appendage Closure (LAAC) (20.34)

CMS has issued a National Coverage Determination for Left Atrial Appendage Closure through Coverage with Evidence Development (CED) for patients that meet approved coverage criteria using an FDA approved device. Effective 2/8/2016 Implementation date: 10/03/2016 ((TN192) (CR9638)
No CDE StudyView Details
5/1/2016Smoking and Tobacco-Use Cessation Counseling (210.4)

7TH maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Percutaneous Transluminal Angioplasty (PTA) (20.7)

7TH maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Mammograms (220.4)

7TH maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Hyperbaric Oxygen Therapy (20.29)

7TH maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Cochlear Implantation (50.3)

7th maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Aprepitant for Chemotherapy-Induced Emesis (110.18)

7th maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Counseling to Prevent Tobacco Use (210.4.1)

7TH maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Cryosurgery of Prostate (230.9)

7TH maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Heart Transplants (260.9)

7TH maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Colorectal Cancer Screening Tests (210.3)

7TH maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
NoView Details
5/1/2016Implantable Automatic Defibrillators (20.4)

7TH maintenance update of ICD-10 and other coding updates. No policy-related changes are included with this update. (TN 1665 )
YesView Details
4/1/2016Adult Liver Transplantation (260.1)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Aprepitant for Chemotherapy-Induced Emesis (110.18)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Bone (Mineral) Density Studies (150.3)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Stem Cell Transplantation Formerly 110.8.1 (110.23)

After 1/27/2016 the use of allogenic HSCT to treat Multiple Myeloma, Myelofibrosis and Sickle Cell Disease will be covered by Medicare if provided in a Medicare-approved clinical study under the CDE paradigm. This transmittal also updates diagnosis codes to ICD-10. See Pub. 100-3, chapter 1, section 110.23 of the NCD Manual for further information. Implementation Date: 10/03/2016. (TN 191 ) (CR9620)
YesView Details
4/1/2016Transcatheter Mitral Valve Repair (TMVR) (20.33)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
YesView Details
4/1/2016Vagus Nerve Stimulation (VNS) (160.18)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Lung Cancer Screening with Low Dose Computed Tomography (LDCT) (210.14)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Sacral Nerve Stimulation for Urinary Incontinence (230.18)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Mammograms (220.4)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Percutaneous Image-Guided Breast Biopsy (220.13)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Colorectal Cancer Screening Tests (210.3)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Extracorporeal Photopheresis (110.4)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
YesView Details
4/1/2016Deep Brain Stimulation for Essential Tremor and Parkinson’s disease (160.24)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
4/1/2016Hyperbaric Oxygen Therapy (20.29)

Transmittal 1630 2/26/2016 has been rescinded and replaced by Transmittal 1658; Correction to spreadsheets has been made with added link to the spread sheet. B/MAC was added to requirement 3. (TN 1658 )
NoView Details
2/1/2016Screening for the Human Immunodeficiency Virus (HIV) Infection (210.7)

CMS feels there is adequate evidence to screen for HIV infection in all people between the ages of 15-65 years who are eligible for benefits under Part A or enrolled in Part B. Effective 04/13/2015 implementation date 3/1/2016. (TN 190 ) (CR9403)
NoView Details
2/1/2016Screening for Cervical Cancer with Human Papillomavirus (HPV) (210.2.1)

Effective 7/9/15 CMS feels evidence is sufficient to add HPV testing with guidelines. Implementation date 03/07/2016 (TN 189 ) (CR9434)
NoView Details


CMS NCD Updates for Clinical Diagnostic Laboratory Services

Please use this link to access the CMS site where Lab NCDs are posted.


How are your medical services covered when you are in a "clinical research study"?

A clinical research study (also called a "clinical trial") is a way that doctors and scientists test new types of medical care, like how well a new cancer drug works. They test new medical care procedures or drugs by asking for volunteers to help with the study. This kind of study is one of the final stages of a research process that helps doctors and scientists see if a new approach works and if it is safe.

Not all clinical research studies are open to members of our plan. Medicare first needs to approve the research study. If you participate in a study that Medicare has not approved, you will be responsible for paying all costs for your participation in the study.

Once Medicare approves the study, someone who works on the study will contact you to explain more about the study and see if you meet the requirements set by the scientists who are running the study. You can participate in the study as long as you meet the requirementsfor the study and you have a full understanding and acceptance of what is involved if you participate in the study.

If you participate in a Medicare-approved study, Original Medicare pays most of the costs for the covered services you receive as part of the study. When you are in a clinical research study, you may stay enrolled in our plan and continue to get the rest of your care (the care that is not related to the study) through our plan.

If you want to participate in a Medicare-approved clinical research study, you do not need to get approval from us or your PCP. The providers that deliver your care as part of the clinical research study do not need to be part of our plan's network of providers.

Although you do not need to get our plan's permission to be in a clinical research study, you do need to tell us before you start participating in a clinical research study.

If you plan on participating in a clinical research study, contact Customer Service (phone numbers are printed on the back cover of this booklet) to let them know that you will be participating in a clinical trial and to find out more specific details about what your plan will pay.

Disclaimers

  • You may join or leave a plan only at certain times. Please call Senior Health Plan at the telephone number listed in the previous section of this web page or 1-800-MEDICARE (1-800-633-4227) for more information. TTY users should call 1-877-486-2048. You can call this number 24 hours a day, seven days a week.
  • You can join Senior Health Plan if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End Stage Renal Disease are generally not eligible to enroll in Senior Health Plan unless they are members of our organization and have been since their dialysis began.
  • Senior Health Plan has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. You can ask for a current Provider Directory for an up-to-date list or search the Senior Health Plan provider directory on this website. If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither Senior Health Plan nor Original Medicare will pay for these services.
  • You must continue to pay your Medicare Part B premium, even if the Senior Health Plan premium is $0.