California PHP

The Centers for Medicare and Medical Services (CMS), which oversees and operates the Medicare program, makes changes to Medicare-covered services throughout year. Because PHP (HMO SNP) is a Medicare Advantage plan with prescription drug coverage, it must cover the services that Medicare covers. The changes listed on this page apply to PHP and the services we cover.

This page lists the changes to Medicare-covered services that are either effective or are to be implemented in 2018 or 2019. The source of this information is CMS’s National Coverage Annual Report. (By clicking on the link above, you will be taken to a website operated by the Centers for Medicare and Medicaid Services, and not PHP.)

1. Acupuncture for Chronic Lower Back Pain (By clicking on the link above, you will be taken to a website operated by the Centers for Medicare and Medicaid Services, and not PHP.)

Effective Date  January 21, 2020

Implementation Date  June 24, 2020

Effective for services performed on or after January, 21, 2020, CMS will cover acupuncture for Medicare patients with chronic Lower Back Pain (cLBP) . Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstance:

For the purpose of this decision, cLBP is defined as:

• Lasting 12 weeks or longer;
• nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc.disease);
• not associated with surgery; and,
• not associated with pregnancy.

An additional 8 sessions will be covered for those patients demonstrating an improvement.  No more than 20 acupuncture treatments may be administered annually.  Treatment must be discontinued if the patient is not improving or is regressing.

2. Ambulatory Blood Pressure Monitoring (By clicking on the link above, you will be taken to a website operated by the Centers for Medicare and Medicaid Services, and not PHP.)

Effective Date  July 2, 2019

Implementation Date  June 16, 2020

For dates of service on and after July 2, 2019, the Centers for Medicare & Medicaid Services (CMS) believes that the evidence is sufficient to determine that ABPM is reasonable and necessary for the diagnosis of hypertension in Medicare beneficiaries under the following circumstances:

1. For beneficiaries with suspected white coat hypertension, which is defined as average office BP of systolic BP > 130 mm Hg but < 160 mm Hg, or diastolic BP > 80 mm Hg but < 100 mm Hg on two separate clinic/office visits with at least two separate measurements made at each visit, and with at least two BP measurements taken outside the office which are < 130/80 mm Hg.
2. For beneficiaries with suspected masked hypertension, which is defined as average office BP between 120 mm Hg and 129 mm Hg for systolic BP, or between 75 mm HG and 79 mm Hg for diastolic BP on two separate clinic/office visits with at least two separate measurements made at each visit, and at least two BP measurements taken outside the office which are ≥ 130/80 mm Hg

ABPM devices must be:

• capable of producing standardized plots of BP measurements for 24 hours with daytime and night-time windows and normal BP bands demarcated; and,
• provided to patients with oral and written instructions and a test run in the physician’s office must be performed; and,
• interpreted by the treating physician or treating non-physician practitioner.

For eligible patients, ABPM is covered once per year.

3. Chimeric Antigen Receptor (CAR) T-cell Therapy (By clicking on the link above, you will be taken to a website operated by the Centers for Medicare and Medicaid Services, and not PHP.)

Effective Date  August 7, 2019

Implementation Date  February 16, 2020

Effective for services performed on or after August 7, 2019, the Centers for Medicare & Medicaid Services (CMS) covers autologous treatment for cancer with T-cells expressing at least one chimeric antigen receptor (CAR) when administered at healthcare facilities enrolled in the FDA risk evaluation and mitigation strategies (REMS) and used for a medically accepted indication as defined at Social Security Act section 1861(t)(2) -i.e., is used for either an FDA-approved indication (according to the FDA-approved label for that product), or for other uses when the product has been FDA-approved and the use is supported in one or more CMS-approved compendia.

4. Next Generation Sequencing (NGS) (By clicking on the link above, you will be taken to a website operated by the Centers for Medicare and Medicaid Services, and not PHP.)

Effective Date  January 27, 2020

Implementation Date  November 13, 2020

Somatic (Acquired) Cancer

Effective for services performed on or after 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 Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following requirements are met:

Patient has:

• either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and
• not been previously tested with the same test using NGS for the same cancer genetic content, and
• decided to seek further cancer treatment (e.g., therapeutic chemotherapy).

The diagnostic laboratory test using NGS must have:

• Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and,
• an FDA-approved or -cleared indication for use in that patient’s cancer; and,
• results provided to the treating physician for management of the patient using a report template to specify treatment options.

Germline (Inherited) Cancer

Effective for services performed on or after January 27, 2020, CMS has determined that NGS as a diagnostic laboratory test is reasonable and necessary and covered nationally for patients with germline (inherited) cancer, when performed in a CLIA-certified laboratory, when ordered by a treating physician and when all of the following requirements are met:

Patient has:

• ovarian or breast cancer; and,
• a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer; and,
• a risk factor for germline (inherited) breast or ovarian cancer; and
• not been previously tested with the same germline test using NGS for the same germline genetic content.

The diagnostic laboratory test using NGS must have all of the following:

• FDA-approval or clearance; and,
• results provided to the treating physician for management of the patient using a report template to specify treatment options.

5. Transcatheter Aortic Valve Replacement (TAVR) (By clicking on the link above, you will be taken to a website operated by the Centers for Medicare and Medicaid Services, and not PHP.)

Effective Date  June 21, 2019

Implementation Date  June 12, 2020

Transcatheter aortic valve replacement (TAVR – also known as TAVI or transcatheter aortic valve implantation) is used in the treatment of aortic stenosis.  A bioprosthetic valve is inserted percutaneously using a catheter and implanted in the orifice of the aortic valve.

6. Vagus Nerve Stimulation (VNS) (By clicking on the link above, you will be taken to a website operated by the Centers for Medicare and Medicaid Services, and not PHP.)

Effective Date  February 15, 2019

Implementation Date  July 22, 2020

Vagus Nerve Stimulation (VNS) is a pulse generator, similar to a pacemaker, that is surgically implanted under the skin of the left chest and an electrical lead (wire) is connected from the generator to the left vagus nerve. Electrical signals are sent from the battery-powered generator to the vagus nerve via the lead. These signals are in turn sent to the brain. The Food and Drug Administration (FDA) approved VNS for treatment of refractory epilepsy in 1997 and for resistant depression in 2005.

If you would like more information about changes to Medicare-covered services, please contact Member Services.