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 2022. Click the "view details" button to read more about the determination and what has changed.

National Coverage Determination Notifications
Posted Coverage Determination Clinical Trial  
9/28/2022Decision Memorandum for Cochlear Implantation

Effective September 26, 2022, The Centers for Medicare & Medicaid Services (CMS) is reconsidering the national coverage determination established at section 50.3 of the Medicare National Coverage Determinations manual. We are expanding coverage by broadening the patient criteria and removing the requirement that for individuals with hearing test scores of > 40 % and ≤ 60 %, cochlear implantation may be covered only when the provider is participating in and patients are enrolled in either an FDA-approved category B IDE clinical trial, a trial under the CMS Clinical Trial Policy, or...
YesView Details
9/27/2022Decision Memorandum for Home Use of Oxygen

On September 27, 2021, CMS issued a national coverage determination (NCD) for Home Use of Oxygen (NCD 240.2). CMS amended the period of initial coverage for these patients from 120 days to 90 days, in order to align with the 90-day statutory time period.
YesView Details
4/7/2022Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease

Effective 4/7/2022, CMS released a national policy for coverage of aducanumab (brand name Aduhelm™) and any future monoclonal antibodies directed against amyloid approved by the FDA with an indication for use in treating Alzheimer's disease. This decision is specific to individuals who have a clinical diagnosis of mild cognitive impairment (MCI) due to Alzheimer's Disease or mild dementia with a confirmed presence of plaque on the brain.
YesView Details
2/18/2022Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)

Effective: 2/10/2022, The Centers for Medicare & Medicaid Services (CMS) is reconsidering the national coverage determination established at section 210.14 of the Medicare National Coverage Determinations manual and has determined that the evidence is sufficient to expand the eligibility criteria for Medicare beneficiaries receiving low dose computed tomography (LDCT) when certain criteria are met. Click the link for details.
YesView 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.