Today is the second time in several months that CMS has reversed (or radically changed) a position on benefit category and policy. The first involved the connection between a stool colon screening test and a colonoscopy, and the second (new) involves a new decision on advanced wheelchair functions being a part of durable medical equipment (DME).
The Colonoscopy Copay Flip
In the earlier decision, in November final rule-making, CMS determined that a colon cancer stool test and a follow-on colonoscopy were part of a continuous process of diagnosis, with the goal that the colonoscopy did not require a copay. (87 FR 69760, 11/18/2022; also stated on p.4 here). (This was separate from lawmaking that a tissue biopsy did not make the colonoscopy require a copay any more).
The CMS decision was interesting because a positive FIT or COLOGUARD test had been triggering a "diagnostic colonoscopy" with a copay, for years and years.
Separately from Medicare, HHS had earlier ruled that a stool-triggered colonoscopy in private insurance did not require a copay (ACA FAQ12-Q5).
The Mobility Device Flip
In the new decision, we turn to power wheelchairs. IN a Benefit Category Determination on July 26, 2006, CMS determined that an "iBOT 4000" had lifting and stair climbing functions that were not medical and therefore not DME. In the new decision - here - CMS rules instead that seat lifting systems ARE a medical function, for example, by preventing shoulder injury caused by stretching up. [*] While the decision is framed as a "Coverage Analysis" a large part of the decision is in fact a "benefit category analysis."
NCDs: Don't Hold Your Breath
The NCD released today, in draft form, is based on a formal 90-page request accessioned in September 2020 (from the ITEM, the Independence Through Enhancement of Medicare & Medicaid Coalition.) So from request to draft, about 2.5 years.
I guess at least one moral could be drawn, if CMS has a formal decision against something, as a matter of law and policy, it's still subject to a 180 degree reversal in a future year.
[*] For example, writing: Users of wheelchairs long term reported that the greatest degree of shoulder pain occurred when performing non-level transfers (Curtis and Roach 1995) while one recent study (Barabareshci and Holland 2019) found that 66% of subjects felt that transfer activity exacerbated their underlying shoulder pain. This hardly seems like major new information since 2006, the negative decision.
See a white paper from HHS on preventive services under the ACA.
The ACA decision about colonoscopy copays following a positive FIT is FAQ 12 Q5.
Basically, a screening colonoscopy used to trigger a copay if there was a tissue biopsy during the procedure. This was changed by law, which took its stakeholders years of jawboning. However, a colonoscopy was still "diagnostic" with a copay if it was triggered by FIT/Cologuard. Which was changed in 11/2022.
One might ask, if a Cologuard and a Colonoscopy are part of one continuous process for CRC screening, why isn't the same true for LDCT and a follow up CT for cause (or biopsy), or a cervical Pap smear and a follow-up cervical biopsy, or a high PSA and a follow up biopsy for cause. The best I can come up with is, well, they ARE all similar in many ways, part of a continuous work up from cancer screening test to cancer diagnostic. However, Colonoscopy is the only one of these that ALSO overlaps and exists in parallel as a standalone, copay-free screening test, which is not true for, say, a lung biopsy.