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National Coverage Determinations

Medicare coverage rules may sometimes change. Below, you’ll find updates for specific services or treatments and their Medicare national coverage determinations.

The Centers for Medicare & Medicaid Services (CMS) sometimes change the coverage rules that apply to an item or service. When this happens, CMS issues a National Coverage Determination (NCD). NCDs may help standardize national health care benefits, serving as guidelines for health care providers and Medicare reimbursement. It tells us:

  • What benefits and services are covered by Medicare
  • What benefits and services are changing
  • What Medicare will pay for an item or service

    • See our NCD notices below.

20252024
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2025 NCD Notices

Effective for claims with dates of service on or after June 9, 2025, contractors shall pay claims for home use of noninvasive positive pressure ventilation (NIPPV) for patients with chronic respiratory failure (CRF) due to chronic obstructive pulmonary disease (COPD) as described in NCD 240.9

To qualify, patients must meet specific medical criteria for either a Respiratory Assist Device (RAD) or a Home Mechanical Ventilator (HMV).

RAD Coverage Criteria:

  • Diagnosis of CRF due to COPD with a partial pressure of carbon dioxide (PaCO₂) of 52 mmHg or greater during awake hours while on prescribed oxygen; and
  • Sleep apnea must not be the primary cause of hypercapnia; and
  • Coverage for RAD with a backup rate feature is available for an initial 6-month period for patients with one of the following characteristics:
    • stable COPD—defined as having no new or worsening symptoms or treatment changes in the prior two weeks; or
    • hypercapnia lasting two weeks or more after hospital discharge for a COPD exacerbation.
  • If high-intensity noninvasive ventilation (NIV) is not tolerated or is medically inappropriate, RAD without a backup rate may be covered for an initial 6-month period when:
    • Diagnosis of CRF due to COPD with a partial pressure of carbon dioxide (PaCO₂) of 52 mmHg or greater during awake hours while on prescribed oxygen; and
    • Sleep apnea is not the primary cause of hypercapnia.
  • Coverage is also available for RADs (with or without backup rate feature) immediately upon hospital discharge for patients with acute on chronic respiratory failure due to COPD, provided they:
    • Required a RAD or ventilator within 24 hours prior to discharge; and
    • Are at risk of rapid symptom exacerbation.

HMV Coverage Criteria:

  • Diagnosis of CRF due to COPD with a partial pressure of carbon dioxide (PaCO₂) of 52 mmHg or greater during awake hours while on prescribed oxygen; and
  • Sleep apnea must not be the primary cause of hypercapnia; and
  • Coverage for HMV is available for an initial 6-month period if the patient meets one of the following conditions:
    • requiring oxygen therapy at an FiO₂ of 36% or greater; or
    • needing ventilatory support for more than eight hours a day; or
    • requiring alarms and internal battery support due to an inability to breathe independently; or
    • having needs that exceed the capabilities of a RAD with backup rate feature.
  • Additionally, HMVs can be covered immediately upon hospital discharge for patients who:
    • Required ventilatory support within 24 hours prior to discharge; and
    • Are at risk of rapid symptom exacerbation or increased PaCO₂ levels.

Ongoing Use Requirements:

Continuing usage requirements stipulate that the device must be used for at least four hours a day on 70% of days, and patients must demonstrate clinical improvement, such as reduced PaCO₂ levels or improved symptoms. Two evaluations are required in the first year: one at six months and another between months seven and twelve.

This summarizes CMS Transmittal 13374, NCD 240.9.

Effective for claims with Dates of Service (DOS) on or after July 2, 2025, contractors shall cover T-TEER for the treatment of symptomatic tricuspid regurgitation (TR) under Coverage with Evidence Development (CED) as described in Medicare NCD 20.38.

Patients must have symptomatic TR that persists despite optimal medical therapy, with tricuspid valve repair being considered as appropriate by a heart team. The decision to proceed with T-TEER must be made by a specialized heart team experienced in the care and treatment of TR. Coverage is limited to procedures performed within a Centers for Medicare & Medicaid Services (CMS)-approved CED study. These studies must enroll only patients who meet the clinical criteria described above and must be conducted by qualified practitioners. The study protocol must be registered with ClinicalTrials.gov and approved by CMS. It must include long-term outcome reporting, such as mortality and hospitalization rates over a minimum of 24 months and incorporate subgroup analyses and rigorous scientific standards. T-TEER procedures performed outside of a CMS-approved study are not covered under this NCD.

This summarizes CMS Transmittal 13366 NCD 20.38.

Effective for claims with dates of service on and after January 13, 2025, contractors shall pay claims for implantable pulmonary artery sensors for heart failure management as described in Pub. 100-03, Medicare NCD Manual, Chapter 1, Section 20.36.

  • The patient must meet all the following criteria: Diagnosis of chronic HF of at least 3 months duration and in New York Health Association (NYHA) functional Class II or III within the past 30 days, prior to pulmonary artery pressure sensor (PAPS) implantation, regardless of left ventricular ejection fraction (LVEF). History of HF hospitalization or urgent HF visit (emergency department (ED) or other outpatient (OP) visit requiring intravenous (IV) diuretic therapy) within the past 12 months, or elevated natriuretic peptides within the past 30 days. On guideline-directed medical therapy (GDMT) for at least 3 months with the goal of achieving optimal or maximally tolerated GDMT prior to PAPS implantation. Evaluated for, and received if appropriate, an implantable cardioverter defibrillator, cardiac resynchronization therapy (CRT)-Pacemaker (CRT-P), or CRT-Defibrillator (CRT-D). Implantation of the device must occur at least 3 months prior to PAPS implantation. No major cardiovascular event (for example, unstable angina, myocardial infarction, percutaneous coronary intervention, open heart surgery, or stroke) within the last 3 months prior to PAPS implantation. Have access to reliable connectivity to ensure daily collection and submission of IPAPS data. Must not have PAPS implantation occur during a hospital

This summarizes CMS Transmittal 13246 NCD 20.36

Effective for claims with dates of service on and after March 19, 2025, Medicare is expanding coverage for Transcatheter Tricuspid Valve Replacement (TTVR) for the treatment of symptomatic tricuspid regurgitation (TR) under Coverage with Evidence Development (CED) as described in Medicare NCD 20.37.

Patients must have symptomatic TR that persists despite optimal medical therapy. The decision to proceed with TTVR must be made by a specialized heart team experienced in the care and treatment of TR. Coverage is limited to procedures performed within a Centers for Medicare & Medicaid Services (CMS)-approved CED study. These studies must enroll only patients who meet the clinical criteria described above and must be conducted by qualified practitioners. The study protocol must be registered with ClinicalTrials.gov and approved by CMS. It must include long-term outcome reporting, such as mortality and hospitalization rates over a minimum of 24 months and incorporate subgroup analyses and rigorous scientific standards. TTVR procedures performed outside of a CMS-approved study are not covered under this NCD.

This summarizes CMS Transmittal 13343 NCD 20.37.

2024 NCD Notices

Effective for claims with dates of service on or after September 30, 2024, Medicare covers these services without cost-sharing (for example, deductibles or co-pays under Part B) to decrease an individual’s risk of acquiring HIV:

  • FDA-approved Pre-exposure Prophylaxis (PrEP) using antiretroviral drugs to prevent HIV in individuals at increased risk of acquiring HIV
  • Administration of injectable PrEP using antiretroviral drugs to prevent HIV
  • Supplying or dispensing the drug regardless of the route of administration (oral and injectable)
  • Individual counseling (up to 8 visits every 12 months), including:
    • HIV risk assessment (initial or continued assessment of risk)
    • HIV risk reduction
    • Medication adherence
  • HIV screenings (up to 8 times every 12 months using FDA-approved laboratory tests and point-of-care tests)
  • Hepatitis B virus screening (1 time only)

Medicare covers HIV prevention services, including PrEP, for people with Medicare at increased risk of acquiring HIV. Physicians and health care practitioners assessing the individual’s history determine if an individual is at increased risk for HIV. To be eligible for counseling, individuals must be competent and alert at the time you provide the counseling.

Some people with Medicare may have previously gotten PrEP for HIV drug coverage through Part D and paid a deductible and coinsurance or copayments. As of September 30, 2024, Part B covers these drugs. If an individual currently has HIV and uses antiretroviral drugs to treat HIV, Part D will continue to cover these drugs, even though these may be the same drugs that are used for HIV PrEP.

This summarizes CMS Transmittal 12987 NCD 110.23

Effective for claims with dates of service on and after March 6, 2024, contractors shall be aware that Medicare is expanding coverage for allogeneic hematopoietic stem cell transplant using bone marrow, peripheral blood or umbilical cord blood stem cell products for Medicare patients with myelodysplastic syndromes who have prognostic risk scores of:

  •  ≥ 1.5 (Intermediate-2 or high) using the International Prognostic Scoring System (IPSS), or
  • ≥ 4.5 (high or very high) using the International Prognostic Scoring System – Revised (IPSS-R), or
  • ≥ 0.5 (high or very high) using the Molecular International Prognostic Scoring System (IPSS-M). In addition, coverage of all other indications for stem cell transplantation not otherwise specified will be made by local Medicare Administrative Contractors under section 1862(a)(1)(A) of the Act.

This summarizes CMS Transmittal 12781 NCD 110.23

Effective for services performed on or after March 6, 2024, allogeneic hematopoietic stem cell transplant using bone marrow, peripheral blood or umbilical cord blood stem cell products for Medicare patients with myelodysplastic syndromes who have prognostic risk scores of:

  • ≥ 1.5 (Intermediate-2 or high) using the International Prognostic Scoring System (IPSS), or
  • ≥ 4.5 (high or very high) using the International Prognostic Scoring System – Revised (IPSS1R), or
  • ≥ 0.5 (high or very high) using the Molecular International Prognostic Scoring System (IPSS1M).

For these patients, the evidence demonstrates that the treatment is reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act (the Act). Coverage of all other indications for stem cell transplantation not otherwise specified above as covered or non-covered will be made by local Medicare Administrative Contractors under section 1862(a)(1)(A).

This summarizes CMS Transmittal 12627 NCD 110.23

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