Coverage gap This is also called the donut hole. It is the part of the Medicare plan where the member pays for prescription drugs. The plan does not pay. The gap occurs after you reach your initial coverage limi
Any organization determination requested by a Medicare Advantage member, appointed representative* or physician for a coverage decision You can submit a precertification by electronic data interchange (EDI), through our secure provider website or by phone, using the number on the member’s ID card....
Medical Necessity Form (aka Physician’s Certification Statement (PCS) or MNF):An MNF is required on routine, non-emergency ambulance transports where the patient has Medicare as their primary insurance. It is helpful to have on file for beneficiaries of Medicare HMOs as well. The form essential...
Aetna follows Centers for Medicare & Medicaid Services (CMS) policy on ventilators with noninvasive interfaces. A CMS National Coverage Determination states that ventilators are covered for the following conditions: “neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure conseq...
The Centers for Medicare & Medicaid Services’ National Coverage Determination for "Extracranial-Intracranial (EC-IC) Arterial Bypass Surgery" (CMS, 1991) stated that "EC-IC arterial bypass surgery is not a covered procedure when it is performed as a treatment for ischemic cerebrovascular disease ...
Medical necessity review of infertility drugs by Aetna Specialty Pharmacy Guideline Management may be bypassed for infertility ART drugs that are for use with infertility medical procedures if the infertility procedure has been approved for coverage under the member’s Aetna medical benefit plan. During...
Furthermore, a recently published Medicare National Coverage Determination (February 8, 2016) considers LAA closure devices not reasonable and necessary and only allows coverage within certain clinical trials (CMS, 2016). The CMS Decision Memorandum states: "At this time, there is insufficient ...
CMS IOM Publication 100-02, Medicare Benefit Policy Manual; CMS IOM Publication 100-03 Medicare National Coverage Determination Manual. Medicare Coverage Determinations: Centers for Medicare & Medicaid Services (CMS), Medicare Coverage Database [Internet]. Baltimore, MD: CMS; updated periodically. Avail...
Note: Aetna follows Medicare DME MAC rules with respect to the usual medically necessary quantity of supplies for positive airway pressure devices. Upon individual review, positive airway pressure devices are considered a medically necessary form of non-invasive ventilation for members with lung disease...
Center for Medicare and Medicaid Services states that the criteria for a power operated vehicle are slightly different than a power wheelchair. A POV is considered medically necessary when all of the basic coverage criteria I.B.(1-3) above have been met and criteria i-vi below are also met...