In-network with Ascension St. John, Hillcrest, OSU Medical and Saint Francis (other providers are available in our network).

National Coverage Determination

A National Coverage Determination (NCD) is a nationwide decision Medicare makes about whether to pay for an item or service.

Below are national coverage determination updates released since January 2024. Click the "view details" button to read more about the determination and what has changed.

National Coverage Determination Notifications
Posted Coverage Determination Clinical Trial  
3/6/2024Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for Myelodysplastic Syndromes (MDS)

The Centers for Medicare and Medicaid Services (CMS) is finalizing the proposed NCD for Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for Myelodysplastic Syndromes (MDS) using bone marrow or peripheral blood stem cell products and is adding coverage to the final NCD to include the use of umbilical cord blood stem cell products.
YesView Details
10/13/2023Beta Amyloid Positron Emission Tomography in Dementia and Neurodegenerative Disease

The Centers for Medicare & Medicaid Services (CMS) is removing the national coverage determination (NCD) at § 220.6.20, ending coverage with evidence development (CED) for positron emission tomography (PET) beta amyloid imaging and permitting Medicare coverage determinations for PET beta amyloid imaging to be made by the Medicare Administrative Contractors (MACs) under § 1862(a)(1)(A) of the Social Security Act (the Act).
YesView Details
10/11/2023Percutaneous Transluminal Angioplasty (PTA) of the Carotid Artery Concurrent with Stenting

Percutaneous Transluminal Angioplasty (PTA) of the Carotid Artery Concurrent with Stenting The Centers for Medicare & Medicaid Services (CMS) finds that coverage of percutaneous transluminal angioplasty (PTA) of the carotid artery concurrent with stenting is reasonable and necessary with the placement of a Food and Drug Administration (FDA) approved carotid stent with an FDA-approved or cleared embolic protection device.
YesView Details
10/3/2023Cochlear Implantation (50.3)

A cochlear implant device is an electronic instrument, part of which is implanted surgically to stimulate auditory nerve fibers, and part of which is worn or carried by the individual to capture, analyze, and code sound. Cochlear implant devices are available in single-channel and multi-channel models. The purpose of implanting the device is to provide awareness and identification of sounds and to facilitate communication for persons who are moderately to profoundly hearing impaired.
YesView Details
10/3/2023Seat Elevation Equipment (Power Operated) on Power Wheelchairs (280.16)

Power seat elevation equipment used with a power wheelchair raises and lowers users while they remain in the seated position. This equipment uses an electromechanical lift system to provide varying amounts of vertical seat to floor height. It does not change the seated angles or the seat’s angle relative to the ground.
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 requirements for 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.