Coverage Updates from Medicare

Medicare has revised the coverage rules for some healthcare procedures. To be covered, procedures generally must be received through a provider in your plan’s provider network, and some services may require prior authorization from Peoples Health.

Questions?

You can learn more about these coverage changes by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week. TTY users should call 1-877-486-2048. If you have received any of these treatments on or after the effective dates and would like to seek reimbursement, contact member services.

Supervised Exercise Therapy for Symptomatic Peripheral Artery Disease

Posted: 9/7/2017
On May 25, 2017, Medicare began covering supervised exercise therapy for members when the therapy is referred by a physician. Members with intermittent claudication (leg cramping typically caused by obstruction of the arteries) are eligible when treatment is for symptomatic peripheral artery disease. Up to 36 sessions over a 12-week period are covered if certain conditions are met. A second referral is required for additional sessions.

Percutaneous Image-Guided Lumbar Decompression for Lumbar Spinal Stenosis

Posted: 6/14/2017
On Dec. 7, 2016, Medicare began covering percutaneous image-guided lumbar decompression (PILD) for members enrolled in certain CMS-approved clinical studies and who have lumbar spinal stenosis. PILD is a noninvasive procedure that uses specially designed instruments to relieve lower back pain from the condition. To be covered, the surgery must be performed on or after the date above.

Percutaneous Left Atrial Appendage Closures

Posted: 6/6/2016
The Centers for Medicare & Medicaid Services issued a mid-year benefit update covering percutaneous left atrial appendage closures when the procedure is done for patients with non-valvular atrial fibrillation and according to an FDA-approved indication for the procedure with an approved device. The coverage applies for services received on or after Feb. 8, 2016. Coverage requires that patients have:

  • A CHADS2 score ≥ 2 or CHA2DS2-VASc score ≥ 3 (these scores are determined by a healthcare provider to help determine stroke risk)
  • A formal shared decision-making interaction—documented in his or her medical record—with an independent non-interventional physician using an evidence-based decision tool for oral anticoagulation medication in patients with non-valvular atrial fibrillation prior to left atrial appendage closures
  • A suitability for short-term warfarin but deemed unable to take long-term oral anticoagulation medication following the conclusion of the shared decision-making interaction