LCD/NCD conflict on coverage of erythropoiesis-stimulating agents
In April 2018 we posted the news that, for erythropoiesis-stimulating agents (cancer/hematology-related medications which stimulate the bone marrow to make red blood cells), there was a coverage determination mismatch between the Medicare Local Coverage Determination (LCD) and National Coverage Determination (NCD). Priority Health followed the National Coverage Determination which, for certain diagnosis codes, has these services as non-covered.
To summarize the conflict, CMS had a National Coverage Determination (NCD) policy 110.21. The MACs (WPS and NGS) have Local Coverage Determinations (LCD) for J0881 and J0885 billed with EC modifier that conflicts with the non-covered diagnosis list for these codes within NCD 110.21.
CMS has reactivated codes
The Centers for Medicare and Medicaid Services (CMS) has now reactivated codes that were non-covered per the policy criteria in NCD 110.21. Therefore the Priority Health policy on erythropoiesis-stimulating agents has also been updated. Find additional information about the impacted NCD here.