Congress recently passed new legislation, however, that allows Medicare coverage of these types of services. Mammography and colorectal cancer screening are preventive services that have also been included in Medicare. Medicare has local carrier contracts with companies that administer the program for both inpatient and outpatient services. Medicare processes 1 billion claims per year at an average cost of 68 cents per claim. Carriers write policies that are submitted to a carrier advisory committee and, after being published for 45 days, take effect.
Coverage varies around the country.
If a procedure is not paid for and there are complaints, a final decision is made by the carrier. HCFA relies in part on FDA findings to determine coverage. Confusion regarding payment for lung reduction surgery prompted HCFA to investigate controlled research studies in this area. After it was found that evidence was insufficient to make a coverage decision, the recommendation was to fund additional clinical trials. As a rule, HCFA does not pay for procedures when there are insufficient clinical data to support their effectiveness.