CMS to end national coverage determinations for artificial hearts

CMS plans to end national coverage determinations for artificial hearts, the agency said Wednesday.

It also proposed changing how it decides whether to cover ventricular assist devices. Under the plan, Medicare Administrative Contractors would figure out if Medicare should pay for a beneficiary’s artificial heart.

“We believe this proposed decision is in the best interest of Medicare beneficiaries since careful patient selection is important, and the MACs are structured to take into account a beneficiary’s particular clinical circumstances to determine which patients will benefit from receiving an artificial heart,” the agency said in a statement.

CMS said its proposed changes to coverage determinations for ventricular assist devices would better align with best practices and provide “additional flexibility for patients and providers to choose the most appropriate treatments.”

Stakeholders have until September 11 to comment on the proposal. The final changes will take effect no later than November 10.

Medicare now covers artificial hearts for beneficiaries enrolled in a clinical study. CMS’ proposed changes would likely increase the number of people that receive artificial hearts covered by Medicare because MACs would decide whether to pay for them based on medical necessity, not enrollment in a clinical study.

“Our updated criteria better reflects the individualized needs of patients with heart failure and expands physicians’ ability to offer the most appropriate treatment options to their patients, both of which will lead to better health outcomes for Medicare beneficiaries,” CMS Administrator Seema Verma said in a statement.

The Trump administration recently produced a grab bag of health policy changes designed to appeal to President Donald Trump’s political supporters who tend to be older than voters as a whole. The president’s allies hope the moves will help him at the ballot box in November.

Under the national coverage determination process, CMS decides what items and services Medicare should cover based on research and public comments. If there is no national coverage determination for an item or service, MACs can choose to cover it.

CMS contracts with MACs—private insurers—to process fee-for-service Medicare claims for inpatient and outpatient services and durable medical equipment in specific geographical areas.

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