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National Coverage Determinations 


National Coverage Determinations

The Centers for Medicare and Medicaid (CMS) periodically releases changes to services covered by Medicare through National Coverage Determinations (NCD). Health plans are required to notify members of these changes. A NCD is a nationwide determination by CMS on whether an item or service is medically necessary. Please check back often to review the most recent updates on Medicare covered services.



Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse

Effective October 14, 2011, CMS covers annual alcohol screening, and for those that screen positive, up to four, brief, face-to-face behavioral counseling interventions per year for Medicare beneficiaries, including pregnant women:

  • who misuse alcohol, but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence (defined as at least three of the following: tolerance, withdrawal symptoms, impaired control, preoccupation with acquisition and/or use, persistent desire or unsuccessful efforts to quit, sustains social, occupational, or recreational disability, use continues despite adverse consequences); and,
  • who are competent and alert at the time that counseling is provided; and,
  • whose counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting.



Screening for Depression in Adults

Effective October 14, 2011, Medicare covers annual screening for adults for depression in the primary care setting that have staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment, and follow-up.



Screening for Sexually Transmitted Infections (STIs) and High-Intensity Behavioral Counseling (HIBC) to Prevent STIs

Effective November 8, 2011, CMS covers screening for chlamydia, gonorrhea, syphilis and hepatitis B, as well as high intensity behavioral counseling (HIBC) to prevent STIs. These screenings are reasonable and necessary for the prevention or early detection of an illness or disability.



Intensive Behavioral Therapy for Cardiovascular Disease

Effective November 8, 2011, CMS covers intensive behavioral therapy for cardiovascular disease (referred to below as a CVD risk reduction visit), which consists of the following three components:

  • encouraging aspirin use for the primary prevention of cardiovascular disease when the benefits outweigh the risks for men age 45-79 years and women 55-79 years;
  • screening for high blood pressure in adults age 18 years and older; and,
  • intensive behavioral counseling to promote a healthy diet for adults with hyperlipidemia, hypertension, advancing age, and other known risk factors for cardiovascular and diet-related chronic disease.



Screening and Counseling for Obesity

Effective November 29, 2011, CMS covers screening and counseling for obesity in a primary care setting. Medicare beneficiaries who screen for a body mass index meeting a specific threshold are eligible for one face-to-face counseling visit per week for one month, followed by one face-to-face counseling visit every other week for an additional five months. If beneficiaries receiving counseling reduce their weight by at least 6.6 pounds during the first six months of counseling, they are eligible for one face-to-face counseling visit every month for an additional six months.