Effective for items and services furnished on or afterJuly 9, 2007, Medicare
covers the routine costs of qualifying clinical trials, as such costs are
defined below, as well as reasonable and necessary items and services used to
diagnose and treat complications arising from participation in all clinical
trials. All other Medicare rules apply.

Routine costs of a clinical trial include all items and services that are
otherwise generally available to Medicare beneficiaries (i.e., there exists a
benefit category, it is not statutorily excluded, and there is not a national
non-coverage decision) that are provided in either the experimental or the
control arms of a clinical trial except:

  * The investigational item or service, itselfunless otherwise covered outside of the clinical trial;
  * Items and services provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient (e.g., monthly CT scans for a condition usually requiring only a single scan); and
  * Items and services customarily provided by the research sponsors free-of-charge for any enrollee in the trial.

Routine costs in clinical trials include:

  * Items or services that are typically provided absent a clinical trial (e.g., conventional care);
  * Items or services required solely for the provision of the investigational item or service (e.g., administration of a noncovered chemotherapeutic agent), the clinically appropriate monitoring of the effects of the item or service, or the prevention of complications; and
  * Items or services needed for reasonable and necessary care arising from the provision of an investigational item or service in particular, for the diagnosis or treatment of complications.

This policy does not withdraw Medicare coverage for items and services that
may be covered according to Local Coverage Determinations(LCDs) or the
regulations on category B investigational device exemptions found in 42 CFR
405.201-405.215, 411.15, and 411.406. For information about LMRPs, refer to
www.lmrp.net, a searchable database of Medicare Administrative Contractor
local policies.

For non-covered items and services, including items and services for which
Medicare payment is statutorily prohibited, Medicare only covers the treatment
of complications arising from the delivery of the non-covered item or service
and unrelated reasonable and necessary care. However, if the item or service
is not covered by virtue of a national non-coverage policy inPub. 100-03,
National Coverage Determination (NCD) Manual, and is the focus of a qualifying
clinical trial, the routine costs of the clinical trial (as defined above)
will be covered by Medicare but the noncovered item or service, itself, will
not.

**A. Requirements for Medicare Coverage of Routine Costs**

Any clinical trial receiving Medicare coverage of routine costs must meet the
following three requirements:

  * The subject or purpose of the trial must be the evaluation of an item or service that falls within a Medicare benefit category (e.g., physicians' service, durable medical equipment, diagnostic test) and is not statutorily excluded from coverage (e.g., cosmetic surgery, hearing aids).
  * The trial must not be designed exclusively to test toxicity or disease pathophysiology. It must have therapeutic intent.
  * Trials of therapeutic interventions must enroll patients with diagnosed disease rather than healthy volunteers. Trials of diagnostic interventions may enroll healthy patients in order to have a proper control group.

The three requirements above are insufficient by themselves to qualify a
clinical trial for Medicare coverage of routine costs. Clinical trials also
should have the following desirable characteristics; however, some trials, as
described below, are presumed to meet these characteristics and are
automatically qualified to receive Medicare coverage:

  1. The principal purpose of the trial is to test whether the intervention potentially improves the participants' health outcomes;
  2. The trial is well-supported by available scientific and medical information or it is intended to clarify or establish the health outcomes of interventions already in common clinical use;
  3. The trial does not unjustifiably duplicate existing studies;
  4. The trial design is appropriate to answer the research question being asked in the trial;
  5. The trial is sponsored by a credible organization or individual capable of executing the proposed trial successfully;
  6. The trial is in compliance with Federal regulations relating to the protection of human subjects; and
  7. All aspects of the trial are conducted according to the appropriate standards of scientific integrity.

**B. Qualification Process for Clinical Trials**

Using the authority found in 1142 of the Social Security Act (the Act)
(cross-referenced in 1862(a)(1)(E) of the Act), the Agency for Healthcare
Research and Quality (AHRQ) will convene a multi-agency Federal panel (the
"panel") composed of representatives of the Department of Health and Human
Services research agencies (National Institutes of Health (NIH), Centers for
Disease Control and Prevention (CDC), the Food and Drug Administration (FDA),
AHRQ, and the Office of Human Research Protection), and the research arms of
the Department of Defense (DOD) and the Department of Veterans Affairs (VA) to
develop qualifying criteria that will indicate a strong probability that a
trial exhibits the desirable characteristics listed above. These criteria will
be easily verifiable, and where possible, dichotomous. Trials that meet these
qualifying criteria will receive Medicare coverage of their associated routine
costs. This panel is not reviewing or approving individual trials. The multi-
agency panel will meet periodically to review and evaluate the program and
recommend any necessary refinements to the Centers for Medicare & Medicaid
Services (CMS).

Clinical trials that meet the qualifying criteria will receive Medicare
coverage of routine costs after the trial's lead principal investigator
certifies that the trial meets the criteria. This process will require the
principal investigator to enroll the trial in a Medicare clinical trials
registry, currently under development.

Some clinical trials are automatically qualified to receive Medicare coverage
of their routine costs because they have been deemed by AHRQ, in consultation
with the other agencies represented on the multi-agency panel to be highly
likely to have the above-listed seven desirable characteristics of clinical
trials. The principal investigators of these automatically qualified trials do
not need to certify that the trials meet the qualifying criteria, but must
enroll the trials in the Medicare clinical trials registry for administrative
purposes, once the registry is established.

Effective September 19, 2000, clinical trials that are deemed to be
automatically qualified are:

  1. Trials funded by NIH, CDC, AHRQ, CMS, DOD, and VA;
  2. Trials supported by centers or cooperative groups that are funded by the NIH, CDC, AHRQ, CMS, DOD, and VA;
  3. Trials conducted under an investigational new drug application (IND) reviewed by the FDA; and
  4. Drug trials that are exempt from having an IND under 21 CFR 312.2(b)(1) will be deemed automatically qualified until the qualifying criteria are developed and the certification process is in place. At that time the principal investigators of these trials must certify that the trials meet the qualifying criteria in order to maintain Medicare coverage of routine costs. This certification process will only affect the future status of the trial and will not be used to retroactively change the earlier deemed status.

The CMS, through the NCD process, through an individualized assessment of
benefits, risks, and research potential, may determine that certain items and
services for which there is some evidence of significant medical benefit, but
for which there is insufficient evidence to support a "reasonable and
necessary" determination, are only reasonable and necessary when provided in a
clinical trial that meets the requirements defined in that NCD.

Medicare will cover the routine costs of qualifying trials that either have
been deemed to be automatically qualified, have certified that they meet the
qualifying criteria, or are required through the NCD process, unless CMS's
Chief Clinical Officer subsequently finds that a clinical trial does not meet
the qualifying criteria or jeopardizes the safety or welfare of Medicare
beneficiaries.

Should CMS find that a trial's principal investigator misrepresented that the
trial met the necessary qualifying criteria in order to gain Medicare coverage
of routine costs, Medicare coverage of the routine costs would be denied under
1862(a)(1)(E) of the Act. In the case of such a denial, the Medicare
beneficiaries enrolled in the trial would not be held liable (i.e., would be
held harmless from collection) for the costs consistent with the provisions of
1879, 1842(l), or 1834(j)(4) of the Act, as applicable. Where appropriate,
the billing providers would be held liable for the costs and fraud
investigations of the billing providers and the trial's principal investigator
may be pursued.

Medicare regulations require Medicare+Choice (M+C) organizations to follow CMS
NCDs. This NCD raises special issues that require some modification of most
M+C organizations' rules governing provision of items and services in and out
of network. The items and services covered under this NCD are inextricably
linked to the clinical trials with which they are associated and cannot be
covered outside of the context of those clinical trials. M+C organizations
therefore must cover these services regardless of whether they are available
through in-network providers. M+C organizations may have reporting
requirements when enrollees participate in clinical trials, in order to track
and coordinate their members' care, but cannot require prior authorization or
approval.

(This NCD last reviewed July 2007.)