04/17/2018

Priority Health

Update on Erythropoiesis Stimulating Agents (ESA) NCD/LCD

Medicare NCD/LCD for Erythropoiesis Stimulating Agents
For Erythropoiesis Stimulating Agents (cancer/hematology related medications which stimulate the bone marrow to make red blood cells), there is 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 has a National Coverage Determination (NCD) policy 110.21 and 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/MAC reviews are ongoing
As of today, we are awaiting a final determination from CMS on their NCD 110.21 diagnosis review. We are aware that CMS is re-reviewing the diagnosis codes that were added to this policy in November 2017, per the updated Change Request Transmittal 2005, released January 18, 2018, which replaces the original released November 9, 2017. Some Medicare Administrative Contractors (such as the one for Michigan, WPS) are awaiting CMS re-review to make a determination on their LCD policies and may be adjusting claims. Per CMS guidelines; the NCD would take precedence over the LCD.

System update and claim adjustments
As we await the final determination from CMS, Priority Health is in the process of updating our system to align with our MAC, WPS, which is delaying implementation of NCD 110.21. We will work with our vendor to update our system over the next few weeks and, if applicable, identify any claim adjustments needed.