How Medicare makes coverage decisions

Just in case you ever asked yourself, “I wonder how Medicare makes coverage decisions?” here’s an answer:

Over the past 30 years, CMS has made about 300 national coverage decisions [NCDs]. By contrast, Medicare’s contractors have made about 9,000 local coverage decisions during the past decade. […]

CMS uses an evidence-based approach to evaluate items and services for coverage. This approach is based on applying the best available medical evidence according to the generally accepted hierarchy of evidence. CMS refers most NCD requests to outside impartial groups to supplement the agency’s scientific and medical expertise. […]

The process of making most NCDs is relatively lengthy because of the many steps involved. […] For the 10 NCDs made in fiscal year 2001, the average time from the date of the decision memorandum (announcing CMS’s intent to implement a decision) to the date of implementation was 156 days. Six of the 10 decisions exceeded CMS’s self-imposed time frame of 180 to 270 days. […]

That’s all at the national level, but there are local coverage decisions too, and many more of them, as described above.

The process for developing a LMRP [local medical review policy] includes drafting language based on a review of medical literature and the contractor’s understanding of local practices. LMRPs must consider and be based on the strongest evidence available. Contractors are required to permit interested parties to submit scientific, evidence-based information and have open meetings for the purpose of discussing draft LMRPs. Carriers must establish carrier advisory committees (CACs) in each state, which provide a forum for information exchange between carriers and physicians.

That’s only part of the story. And, there is an equally complex appeals process too. More from the MedPAC publication (pdf) from which I excerpted the above. Aren’t you sorry you asked?

Anybody know how private plans do it (with links)? Does Medicare tend to follow private plans or vice versa?

UPDATE: Paul Kelleher tweets, “@afrakt pp. 6, 11, 22 of Baicker/Chandra suggest private coverage follows —They

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