June 2007
Provider Types Affected
Physicians and providers submitting claims to Medicare contractors (Fiscal Intermediaries (FIs), Part Medicare Administrative Contractors (MACs) and carriers)
What Providers Need to Know
Effective for claims with dates of service on or after March 20, 2007, the use of osmotic blood brain barrier disruption is not considered reasonable and necessary when it is used as part of a treatment regimen for brain tumors in Medicare patients.
Background
This article and Change Request (CR) 5530 states that Medicare does not currently have a national coverage determination (NCD) for osmotic blood brain barrier disruption (BBBD) as part of a treatment regimen for brain tumors. The Centers for Medicare & Medicaid Services (CMS) accepted a formal request for non-coverage of BBBD used for this indication.
CMS determined that the use of osmotic blood brain barrier disruption is not reasonable and necessary when it is used as part of a treatment regimen for brain tumors. Be aware that the BBBD process includes all items and services necessary to perform the procedure, including hospitalization, monitoring, and repeated imaging procedures. This NCD does not alter in any manner the coverage of anti-cancer chemotherapy.
Additional Information
CR5530 is the official instruction issued to your Medicare FI, Carrier or MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R67NCD.pdf on the CMS website.
If you have questions, please contact your state's Provider Contact Center.
MLN Matters MM5530