NCDs, LCDs, Discharge Planning, and Home Care – All in One Article

My topic list has been overflowing with information lately, so it’s time for another rapid-fire article.

First up, a few weeks ago the Centers for Medicare & Medicaid Services (CMS) announced that they have withdrawn the national coverage determination (NCD) for amyloid PET scans used to diagnose and monitor the response to treatment of Alzheimer’s disease. The NCD previously allowed one amyloid PET scan for patients who were participating in clinical trials. However, that became a problem when CMS approved payment for Leqembi outside of clinical trials. Patients needed a PET scan to see if the drug was right for them, but it was unclear if Medicare would pay for it.

Now, having the NCD completely withdrawn is both good and bad news. The good news, of course, is that there are no specific requirements from CMS to obtain an amyloid PET scan. But the bad news is that it leaves coverage to the discretion of the Medicare Administrative Contractors (MACs). Will the MACs place specific requirements on coverage? Will each MAC come up with its own requirements, creating a patchwork of coverage, depending on the state where the patient resides? The treatment guidelines recommend using the PET scan to monitor response to the treatment, but how often will the MACs allow a follow-up PET scan to be done? If you are performing these scans now, I would ensure that the documentation supports performing the PET scan prior to initiation of Leqembi, and for monitoring, that it is present in the medical record – and try to ensure that the treatment plan matches the treatment guidelines.

Next, the American College of Rheumatology and the American Academy of Hip and Knee Surgeons recently met and developed clinical guidelines related to the timing of elective joint replacement surgery. Their conclusion was that the timing should be a shared decision between the patient and the surgeon and that there is no role for specific time frames for trials of conservative therapy. Several MACs have local coverage determinations (LCDs) specifying a three-month trial of conservative care. As they describe, patients who see orthopedists for arthritis have most likely already received treatment from their primary care physician and tried over-the-counter medications and have failed that therapy, so subjecting the patients to a mandatory three-month period of more conservative care is not appropriate. Now, what will happen with this? Well, I have formally requested that two MACs revise their LCDs.

I can report that one MAC has already responded, noting that my submission was “invalid” because although I included the clinical guidelines from two very prominent professional societies, I did not include “full copies of published literature to support your specific request for revision.” Should I have printed out every one of the 58 references used in developing the guideline? Maybe next time…

Next, last week I wrote about discharge planning and CMS’s statement that your choice list for post-acute providers does not need to include providers, specifically skilled nursing facilities (SNFs), that do not have open beds. Well, this week I can report another change. If you read the Federal Register from 2019, it states that “hospitals must not develop preferred lists of providers.” That is pretty definitive. It was generally thought that hospitals could not formally designate any facility as “preferred” on the choice list.

But Alicia Tennenbaum from Mount Sinai in New York sent me a copy of a notice where CMS states that the term “preferred provider” can be used to label post-acute providers on the list provided to patients, as long as the list includes all the other facilities that can provide the needed care and the quality and resource use data for every facility, including the preferred providers.

When I first read this, it made me nervous, but perhaps all CMS was saying back in 2019 was that they did not want hospitals to only offer the patient the choice of their preferred facilities.

Finally, Livanta’s newsletter had a story of a patient who was hospitalized with a stroke and sent home with home care. The daughter called Livanta, because after a week, no one from the home care agency had shown up, and her calls to the agency were not answered. Livanta contacted the hospital, the case manager contacted the home care agency, and the agency told the case manager they declined the patient due to understaffing. What? Who messed that one up? I certainly hope there is more to this story. I cannot believe the hospital would refer a patient to a home care agency and not confirm they accepted the patient. And I cannot believe the home care agency would accept a patient, then decline the patient, without notifying the hospital or the patient. But whatever happened here, I do know that the hospital has to recode their claim since home care did not begin within three days of discharge, and as a result, the discharge status code should be 01 and not 06.