Tufts Health Plan Medicare Preferred Updates

As a Medicare Advantage Organization, Tufts Medicare Preferred must follow Medicare coverage guidelines. Network providers should be aware of the following recent Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), which can be accessed online at the CMS Web site, cms.hhs.gov.

Pharmacogenomic Testing to Predict Warfarin Responsiveness (NCD 90.1)
On January 5, 2010, CMS announced that coverage of pharmacogenomic testing to predict warfarin responsiveness is restricted to patients participating in a clinical trial who 1) are candidates for anticoagulation therapy with warfarin, 2) have not been previously tested for CYP2C9 or VKORC1 alleles, and 3) have received fewer than five days of warfarin in the anticoagulation regimen for which the testing is ordered. CMS further limits coverage of the test to once per lifetime for qualifying members. For details, refer to CMS document MM6715.

Collagen Meniscus Implant
On February 24, 2010, CMS proposed that the collagen meniscus implant does not improve health outcomes. Therefore, CMS has determined that the collagen meniscus implant is not reasonable and necessary for the treatment of meniscal injury/tear and proposes a national non-coverage determination. For details, refer to the CMS Proposed Decision Memo for Collagen Meniscus Implant (CAG-00414N).

PET (NaF-18) Imaging to Identify Bone Metastasis of Cancer
In a final decision, released on February 26, 2010, CMS stated that if a member is part of a qualifying clinical trial, NaF-18 PET imaging may be covered if the member’s treating physician determines that the NaF-18 PET study is needed to inform the initial antitumor treatment strategy or to guide subsequent antitumor treatment strategy after the completion of initial treatment. For further coverage information refer to the CMS Final Decision Memo for Positron Emission Tomography (NaF-18) to Identify Bone Metastasis of Cancer (CAG-00065R).

May 1, 2010