The Centers for Medicare & Medicaid Services (CMS) have finalized a
national coverage policy for chimeric antigen receptor (CAR) T-cell therapies
Kymriah™ and Yescarta™. As of January 1, 2019,
coverage and reimbursement for CAR T-cell therapy for Independence Medicare
Advantage members is processed through the local Medicare Administrative
Contractor (MAC) for calendar years 2019 and 2020.
Background
CMS identified CAR T-cell therapy as meeting the significant cost threshold.
When CMS identifies a service has met this threshold, the Medicare Advantage
plan is not responsible for the processing of claims or the provision of
traditional medical management for the service, during the specified time
period. In order for claims to be processed correctly, providers must submit
all claims for CAR T-cell therapy and associated costs to the local MAC.
Claims submission
Claims for CAR T-cell therapy should not be submitted to the Medicare
Advantage plan. If claims are not submitted properly, providers will receive a
message to submit these services to the appropriate Medicare fiscal
intermediary or carrier for coverage and payment determination.
Policy updates
Independence Medicare Advantage policy #MA08.093e: Chimeric Antigen Receptor
(CAR) Therapy was reviewed to determine if any changes were required based on
the CMS policy.
The following changes were made:
- This policy has been updated to communicate coverage and reimbursement for
CAR-T Cell therapy for Independence Medicare Advantage members will be
processed through the local MAC, as this therapy has been identified as meeting
Medicare's the significant cost threshold.
- The following CPT codes havebeen added to this
policy:
- 0537T, 0538T, 0539T, 0540T
- All ICD-10 CM codes
have been deleted from
Attachment A of this policy.
Learn more
To view this policy, visit our Medical Policy Portal.
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