Medicare Coverage Updates December 2010

Ventricular Assist Devices as Destination Therapy

Effective for dates of service on and after November 9, 2010, CMS expanded the National Coverage Determination (NCD) criteria for Ventricular Assist Devices (VADs) as Destination Therapy. VAD implantation as destination therapy is covered when:

• The device is FDA approved for destination therapy,
• Performed in a hospital that is Medicare approved to provide this procedure, and
• The patient has:  

1.  
   1.  NYHA Class IV end-stage ventricular heart failure but is not a candidate for heart transplant
   2. Failed to respond to optimal medical management (including beta-blockers, and ACE inhibitors if tolerated) for at least 45 of the last 60 days, or have been balloon pump-dependent for 7 days, or IV inotrope-dependent for 14 days
   3. A left ventricular ejection fraction (LVEF) < 25%; and,
   4. Demonstrated functional limitation with a peak oxygen consumption of <14 ml/kg/min unless balloon pump or inotrope dependent or physically unable to perform the test.

For complete information, see the Transmittal 129 or MLN Matters Article MM7220.

Cahaba NCD Article - Sterilization

Effective December 1, 2010, Cahaba GBA has added an NCD Article to the coverage database that lists the sterilization CPT codes that are not covered when billed with ICD-9 code V25.2, Sterilization. Sterilization is only covered when it is part of a necessary treatment for an illness or injury.

Cahaba NCD Article – Hyperbaric Oxygen Therapy Update

Effective December 1, 2010, Cahaba GBA added the following covered ICD-9 codes to the HBO article.

• 250.80 – 250.83, Diabetes with other specified manifestations
• 595.82, Irradiation cystitis