Skip to Content

National Coverage Determination updates

Get the latest updates on your Medicare coverage.

Security Health Plan is a HMO-POS, MSA and D-SNP plan with a Medicare contract and a contract with the Wisconsin Medicaid program. Enrollment in Security Health Plan depends on contract renewal. As a member of a Medicare Advantage plan offered by Security Health Plan, you get all of the usual Medicare services that are covered for everyone with Original Medicare. The Centers for Medicare and Medicaid Services (CMS) also release periodic National Coverage Determinations (NCDs) for new medical services, treatments and procedures that must be covered by Medicare Advantage plans under certain conditions.

The following list summarizes the NCDs released most recently. For detailed information on these or any other NCDs ask your physician or   click here for the Medicare NCD index.

If you have questions please call our Customer Service Department at 1-877-998-0998 (TTY 711). We are open 8 a.m. to 8 p.m., 7 days a week. Outside of these hours and on weekends from April 1-Sept. 30, please leave a voicemail and we will return your call the next business day.

Procedure

National Coverage Determination

Magnetic resonance Imaging (MRI) Effective April 10, 2018

The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to conclude that magnetic resonance imaging (MRI) for Medicare beneficiaries with an implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), or cardiac resynchronization therapy defibrillator (CRT-D) is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member under section 1862(a)(1)(A) of the Social Security Act under certain circumstances. Thus, we will modify our national coverage determination to eliminate the collection of additional information under the Coverage with Evidence Development paradigm under section 1862(a)(1)(E) of the Social Security Act.

In general, we:

  • revise the language in section 220.2(C)(1) to remove the contraindication for Medicare coverage of MRI in a beneficiary who has an implanted pacemaker or implantable cardioverter defibrillator;
  • expand coverage to include cardiac resynchronization therapy pacemaker, or cardiac resynchronization therapy defibrillator devices;
  • expand coverage for beneficiaries who have an implanted FDA-approved pacemaker, implantable cardioverter defibrillator, cardiac resynchronization therapy pacemaker, or cardiac resynchronization therapy defibrillator correspondingly under 220.2(B)(3) of the NCD Manual as a Nationally Covered MRI indication;
  • expand coverage for beneficiaries with an implanted pacemaker, implantable cardioverter defibrillator, cardiac resynchronization therapy pacemaker, or cardiac resynchronization therapy defibrillator device that do not have FDA labeling specific for an MRI with certain criteria;
  • remove the Coverage with Evidence Development requirement.
Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer Effective March 16, 2018

The Centers for Medicare & Medicaid Services (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 all of the following requirements are met:

  1. Patient has:
    1. either recurrent, relapsed, refractory, metastatic, or advanced stages III or IV cancer; and
    2. either not been previously tested using the same NGS test for the same primary diagnosis of cancer or repeat testing using the same NGS test only when a new primary cancer diagnosis is made by the treating physician; and
    3. decided to seek further cancer treatment (e.g., therapeutic chemotherapy).
  2. The diagnostic laboratory test using NGS must have:
    1. FDA approval or clearance as a companion in vitro diagnostic; and
    2. an FDA approved or cleared indication for use in that patient’s cancer; and
    3. results provided to the treating physician for management of the patient using a report template to specify treatment options.

Medicare Administrative Contractors (MACs) may determine coverage of other Next Generation Sequencing (NGS) as a diagnostic laboratory test for patients with cancer only when the test is performed in a CLIA-certified laboratory, ordered by a treating physician and the patient has:

  1. either recurrent, relapsed, refractory, metastatic, or advanced stages III or IV cancer; and
  2. either not been previously tested using the same NGS test for the same primary diagnosis of cancer or repeat testing using the same NGS test only when a new primary cancer diagnosis is made by the treating physician; and
  3. decided to seek further cancer treatment (e.g., therapeutic chemotherapy).
Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS)

Effective December 7, 2016

The Centers for Medicare & Medicaid Services (CMS) since January 2014 has covered PILD procedures for LSS (a cause of lower back pain) when provided in an approved clinical study to determine if PILD improves health outcomes such as function and/or quality of life, reduces pain or reduces use of other medical treatments or services in Medicare beneficiaries, as compared to other treatments. This is now expanded to cover a prospective longitudinal study of PILD procedures using an FDA-approved/cleared device if the study completed a CMS-approved randomized clinical trial that met established criteria.

Screening for Hepatitis B Virus (HBV) Infection

Effective September 28, 2016

The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to conclude that screening for Hepatitis B Virus (HBV) infection is reasonable and necessary for the prevention or early detection of an illness or disability. CMS will cover screening for Medicare beneficiaries who meet either of the following conditions:

  • Asymptomatic, nonpregnant adolescents and adults at high risk for HBV infection. "High risk" is defined as
    • Persons born in countries and regions with a high prevalence of HBV infection,
    • U.S.-born persons not vaccinated as infants whose parents were born in regions with a very high prevalence of HBV infection,
    • HIV-positive persons, men who have sex with men, injection drug users, household contacts or sexual partners of persons with HBV infection.
    • In addition, CMS has determined that repeated screening would be appropriate annually only for beneficiaries with continued high risk (i.e., men who have sex with men, injection drug users, household contacts or sexual partners of persons with HBV infection) who do not receive hepatitis B vaccination.
  • At the first prenatal visit for pregnant women and then rescreening at time of delivery for those with new or continuing risk factors.
  • In addition, CMS has determined that screening during the first prenatal visit would be appropriate for each pregnancy, regardless of previous hepatitis B vaccination or previous negative hepatitis B surface antigen (HBsAg) test results.
Smoking and tobacco-use cessation counseling

Effective date September 30, 2015

The Centers for Medicare & Medicaid Services (CMS) removed the National Coverage Determination on Smoking and Tobacco-Use Cessation Counseling (210.4).CMS removed this NCD because it is older than 10 years and a more recent policy has since been published. The more recent preventive service policy related to cessation services entitled Counseling to Prevent Tobacco Use (210.4.1) will remain effective and better serves the needs of Medicare beneficiaries because those services do not impose cost-sharing obligations.

Screening for Human Immunodeficiency Virus (HIV) infection

Effective date April 13, 2015

The Centers for Medicare & Medicaid Services (CMS) is expanding coverage to include screening for HIV infection for all beneficiaries between the ages of 15 and 65 entitled to benefits under Part A or enrolled under Part B. CMS will cover a maximum of one, annual voluntary screen for all adolescents and adults age 15 to 65, without regard to perceived risk. CMS will cover a maximum of one, annual voluntary screening for adolescents younger than 15 and adults older than 65 who are at increased risk for HIV infection if certain criteria are met. CMS will cover a maximum of three, voluntary HIV screenings of pregnant Medicare beneficiaries: 1) when the pregnancy is known, 2) during the third trimester, and 3) at labor, if ordered by the woman's clinician.

Screening for lung cancer with low dose computed tomography (LDCT)

Effective date February 5, 2015

The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to add a lung cancer screening counseling visit, and for appropriate beneficiaries, annual screening for lung cancer with low dose computed tomography (LDCT), as an additional preventive service benefit under the Medicare program only if certain criteria are met. Beneficiary eligibility criteria:

  • Age 55 – 77 years
  • Asymptomatic (no signs or symptoms of lung cancer)
  • Tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes)
  • Current smoker or one who has quit smoking within the last 15 years

Receives a written order for LDCT lung cancer screening that meets criteria

No NCD for microvolt T-wave alternans testing for patients at risk of sudden cardiac death

Effective date January 13, 2015

The Centers for Medicare & Medicaid Services has decided that no National Coverage Determination (NCD) is appropriate at this time for microvolt T-wave alternans (MTWA) testing using the modified moving average (MMA) method for the evaluation of patients at risk for sudden cardiac death (SCD). National non-coverage will be removed. Medicare coverage of MTWA using the MMA method will be determined by the local contractors.

Removal of National Coverage Determinations

Effective date December 18, 2014

Effective 12/18/14 the Centers for Medicare & Medicaid Services removes the following NCDs from the NCD Manual (100-03):

  • 50.6 - Tinnitus masking
  • 160.4 - Stereotactic Cingulotomy as a Means of Psychosurgery
  • 160.6 - Carotid Sinus Nerve Stimulator
  • 160.9 - Electroencephalographic (EEG) Monitoring During Open-Heart Surgery
  • 190.4 - Electron Microscope
  • 220.7 - Xenon Scan
  • 220.8 - Nuclear Radiology Procedure

CMS retains the following NCDs:

  • 20.17 - Noninvasive Tests of Carotid Function
  • 140.5 - Laser Procedures
  • 160.17 - L-DOPA

When NCDs are removed, the coverage decision reverts to the regional Medicare Administrative Contractors.

Screening for colorectal cancer - stool DNA testing

Effective date October 9, 2014

The Centers for Medicare & Medicaid Services has determined that the evidence is sufficient to cover CologuardTM – a multitarget stool DNA test – as a colorectal cancer screening test for asymptomatic, average risk beneficiaries, aged 50 to 85 years. All other screening stool DNA tests not otherwise specified remain nationally non-covered.

Transcatheter mitral valve repair (TMVR)

Effective date August 7, 2014

The Centers for Medicare & Medicaid Services (CMS) covers transcatheter mitral valve repair (TMVR) under the following conditions:

  1. TMVR is covered for the treatment of significant symptomatic degenerative mitral regurgitation when furnished according to an FDA approved indication and when certain conditions are met.
  2. TMVR is covered for uses that are not expressly listed as an FDA approved indication when performed within a FDA-approved randomized controlled trial that fulfills certain requirements.
  3. All CMS-approved clinical trials and registries must adhere to standards of scientific integrity and relevance to the Medicare population.
Screening for Hepatitis C virus (HCV) in adults

Effective date June 2, 2014

The Centers for Medicare & Medicaid Services will cover screening for the Hepatitis C Virus with the appropriate U.S. Food and Drug Administration approved laboratory tests, when ordered by the beneficiary’s primary care physician or practitioner for beneficiaries who meet either of these conditions:

  1. Adults at high risk for HCV infection. “High risk” is defined as persons with a current or past history of illicit injection drug use; and persons who have a history of receiving a blood transfusion prior to 1992. Repeat screening for high risk persons is covered annually only for persons who have had continued illicit injection drug use since the prior negative screening test.
  2. A single screening test is covered for adults who do not meet the high risk as defined above, but who were born from 1945 through 1965.

Intensive cardiac rehabilitation (ICR) includes Benson-Henry Institute Cardiac Wellness Program

Effective date May 4, 2014

The Centers for Medicare & Medicaid Services is expanding the intensive cardiac rehabilitation (ICR) benefit to include the Benson-Henry Institute Cardiac Wellness Program. This program is a multicomponent intervention program that includes supervised exercise, behavioral interventions and counseling and is designed to reduce cardiovascular risk and improve health outcomes.

 

Security Health Plan and its agents are not in any way connected with the Medicare program. Security Health Plan of Wisconsin, Inc., is an HMO-POS, MSA and D-SNP plan with a Medicare contract and a contract with the Wisconsin Medicaid program. Enrollment in Security Health Plan depends on contract renewal.

This information is not a complete description of benefits. Call Customer Service at 1-877-998-0998 (TTY 711 ) for more information.

Y0117_MC-778-0628-C-09-18