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CMS Is Considering Extending Coverage of Screening Tests

August 25, 2009:

The Centers for Medicare & Medicaid Services (CMS) is contemplating coverage of HIV and genetic screening. 

HIV screening: Due to the addition of other screening services added to the Medicare allowable payment schedule, CMS is now evaluating whether screening for HIV in those patients who may be at risk of this disease warrants development of a national coverage determination. The United States Preventive Services Task Force (USPSTF) has established criteria classifying certain preventative services as grade A, where it is strongly recommended, or grade B, where it recommends such screenings. It is this classification that has allowed the review of HIV screening since it may comply with statutes as listed under section 101(a) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (Public Law 110-275). If the end result of the investigation suggests that this service is recommended, then it will allow CMS under 42 CFR 410.64 to cover this screening as detailed in Title XVIII of the act.

A proposed decision is expected September 13, 2009, followed by completion of the national coverage analysis by December 9, 2009.

Screening genetic tests: CMS is currently reviewing DNA testing as a preventative measure to determine if this testing improves the health of the Medicare population. Genetic screening may be beneficial in detecting traits of disease prior to the presentation of symptoms; however, the lack of evidence that such testing is clinically appropriate presents concerns about whether or not there are benefits to the patient population. CMS is researching what characteristics warrant this screening and if, in fact, this screening reduces disease complications or increases life expectancy. Additionally, the agency has requested that the Medicare Evidence Development and Coverage Advisory Committee (MedCAC) pinpoint areas of discrepancy within current information that may be cause for further research into this topic. For this reason, a public meeting was held May 6, 2009.

Screening tests present a special concern for Medicare, as compared with diagnostic testing, since the patient generally presents without symptoms. Screening services must therefore meet a few requirements before they are considered for coverage:

  • They must be reasonable and necessary for early detection/prevention.
  • The services must fall under the grade A or grade B classification as defined by the United States Preventive Services Task Force (USPSTF).
  • They must be appropriate for Medicare beneficiaries.

Karen H. Kachur, CPC
Clinical/Technical Editor


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