(Medicare National Coverage Determinations Manual)

1833(u)  (6) Physician Defined. For purposes of this paragraph, the term "physician" means a physician described in section 1861(r)(1) and the term "primary care physician" means a physician who is identified in the  available data as a general practitioner, family practice practitioner, general internist, or obstetrician or  gynecologist.  1833(x)(2)(A)(i)  (I) is a physician (as described in section 1861(r)(1)) who has a primary specialty designation of  family medicine, internal medicine, geriatric medicine, or pediatric medicine;  or  (II) is a nurse practitioner, clinical nurse specialist, or physician assistant (as those terms are defined in section 1861(aa)(5)).   C. Nationally Non -Covered Indications   Effective for claims with dates of service on and after September 28,  2016:   - Medicare beneficiaries who are symptomatic, or who have already been diagnosed with HBV infection, or who are nonpregnant and have already received a hepatitis B vaccination are non-covered.  D. Other  Medicare coinsurance and the Part B deductible are waived for this "additional preventive  service."   (NCD updated September 2016)   210.7  Screening for Human Immunodeficiency Virus (HIV)  (Rev.  190, Issued: 02- 05-16; Effective: 04 -13-15; Implementation: 03 -07-16 - non-shared A/B MAC edits; 07 -05-16 - CWF analysis and design; 10- 03-16 - CWF Coding, Testing and Implementation, MCS, and FISS Implementation; 01 -03-17 - Requirement 9403.04.9)   A. General   Human Immunodeficiency Virus (HIV) is an infection caused by a retrovirus that affects the immune system.  HIV infection causes acquired immune deficiency syndrome (AIDS), a disease which severely compromises an individuals immune system.  It is currently generally accepted that antiretroviral therapy (ART) has significantly reduced HIV -associated morbidity and mortality throughout the world and the United States, and has transformed HIV disease for many, into a chronic, manageable condition.  There is als o evidence that the use of ART is associated with a substantially decreased risk for transmission of the virus to uninfected persons.   Effective January 1, 2009, the Centers for Medicare & Medicaid Services (CMS) is allowed to add coverage of additional preventive services through the national coverage determination (NCD) process if certain statutory requirements are met, as provided in 42 C.F.R. 410.64 (CMS began covering HIV screening effective December 8, 2009).  One of those requirements is that the service(s) be categorized as a Grade A (strongly recommends) or Grade B (recommends) rating by the United States Preventive Services Ta sk Force (USPSTF).  The USPSTF gives a Grade A recommendation to screening for HIV in:    All adolescents and adults between the ages of 15 to 65 years,   Younger adolescents and older adults who are at increased risk of HIV infection, and,  All pregnant women.   B. Nationally Covered Indications   Effective for claims with dates of service on and after April 13, 2015, CMS has determined that the evidence is adequate to conclude that screening for HIV infection for all individuals between the ages of 15 and 65 years, as recommended with a Grade of A by the USPSTF, is reasonable and necessary for early detection of HIV and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B.   CMS shall cover screening for HIV with the appropriate U.S. Food and Drug Administration (FDA) -approved laboratory tests and point -of-care tests, used consistent with FDA -approved labeling and in compliance with the Clinical Laboratory Improvement Act (CLI A) regulations, when ordered by the beneficiarys physician or practitioner within the context of a healthcare setting and performed by an eligible Medicare provider for these services, for beneficiaries who meet one of the following conditions:   1. Except for pregnant Medicare beneficiaries addressed below, a maximum of one, annual, voluntary screening for all adolescents and adults between the age of 15 and 65, without regard to perceived risk.   2. Except for pregnant Medicare beneficiaries addressed below, a maximum of one, annual, voluntary screening for adolescents younger than 15 and adults older than 65 who are at increased risk for HIV infection.  Increased risk for HIV infection is defined as follows:    Men who have sex with men,   Men and women having unprotected vaginal or anal intercourse,   Past or present injection drug users,   Men and women who exchange sex for money or drugs, or have sex partners who do,  Individuals whose past or present sex partners were HIV -infected, bisexual, or injection drug users,   Persons who have acquired or request testing for other sexually transmitted infectious diseases,   Persons with a history of blood transfusions between 1978 and 1985,   Persons who request an HIV test despite reporting no individual risk factors,  Persons with new sexual partners,   Persons who, based on individualized physician interview and examination, are deemed to be at increased risk for HIV infection.  The determination of increased risk for HIV infection is identified by the health care practitioner who assesses the patient s history, which is part of any complete medical history, typically part of an annual wellness visit and considered in the development of a comprehensive prevention plan.  The medical recommendation should be a reflection of the service provided.   3. A maximum of three, voluntary, HIV screenings of pregnant Medicare beneficiaries: (1) when the diagnosis of pregnancy is known, (2) during the third trimester, and, (3) at labor, if ordered by the womans clinician.   C. Nationally Non -Covered Indications   Effective for claims with dates of service on and after April 13, 2015:   -Medicare beneficiaries with any known diagnosis of an HIV -related illness are not eligible for this screening test.   -Medicare beneficiaries between the ages of 15 and 65 who have had a prior HIV screening test within 1 year are not eligible for HIV screening (i.e., at least 11 full months must have elapsed following the month in which the previous test was performed in order for the subsequent test to be covered).    -Medicare beneficiaries younger than 15 or older than 65, at increased risk for HIV -related illnesses, who have had a prior HIV screening test within 1 year are not eligible for HIV screening (i.e., at least 11 full months must have elapsed following the m onth in which the previous test was performed in order for the subsequent test to be covered).   -Pregnant Medicare beneficiaries who have had three specified screening tests within each respective term of pregnancy are not eligible for further HIV screening during their pregnancy.   D. Other   N/A  (This NCD last reviewed April 2015.)   210.8  Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse  (Effective October 14, 2011)  (Rev. 138, Issued: 11- 23-11, Effective: 10 -14-11, Implementation: 12- 27-11 non -system changes, 04- 02-12 shared system changes, 07- 02-12 CWF/HICR/MCS MCSDT)   A. General   Based upon authority to cover additional preventive services for Medicare beneficiaries if certain statutory requirements are met, the Centers for Medicare & Medicaid Services (CMS) initiated a new national coverage analysis on annual screening and brief  behavioral counseling in primary care to reduce alcohol misuse in adults, including pregnant women.  Annual screening and behavioral counseling for alcohol misuse in adults is recommended with a grade of B by the U.S. Preventive Services Task Force (USPST F) and is appropriate for individuals entitled to benefits under Part A and Part B.  CMS will cover annual alcohol screening and up to four, brief face -to-face behavioral counseling in primary care settings to reduce alcohol misuse. CMS does not identify specific alcohol misuse screening tools.  Rather, the decision to use a specific tool is at the discretion of the clinician in the primary care setting. Various screening tools are available for screening for alcohol misuse.   B. Nationally Covered Indications   Effective for claims with dates of service on or after October 14, 2011, CMS will cover annual alcohol screening, and for those that screen positive, up to four brief, face -to-face, behavioral counseling interventions per year for Medicare beneficiaries, i ncluding pregnant women:    Who misuse alcohol, but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence (defined as at least three of the following: tolerance, withdrawal symptoms, impaired control, preoccupation with acquisition and/or use, persistent desire or unsuccessful efforts to quit, sustains social, occupational, or recreational disability, use continues despite adverse consequences); and   Who are competent and alert at the time that counseling is provided; and,   Whose counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting.   Each of the behavioral counseling interventions should be consistent with the 5As approach that has been adopted by the USPSTF to describe such services. They are:   1. Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.  2. Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.   3. Agree: Collaboratively select appropriate treatment goals and methods based on the patients interest in and willingness to change the behavior.   4. Assist: Using behavior change techniques (self -help and/or counseling), aid the patient in achieving agreed upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treat ments when appropriate.   5. Arrange: Schedule follow -up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.   For the purposes of this policy, a primary care setting is defined as one in which there is provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities and hospices are not considered primary care settings under this definition.  For the purposes of this policy a primary care physician and primary care practitioner are to be defined based on two existing sections of the Social Security Act, 1833(u)(6), 1833(x)(2)(A)(i)(I) and 1833(x)(2)(A)(i)(II):   1833(u)  (6)Physician Defined. For purposes of this paragraph, the term physician means a physician described in section 1861(r)(1) and the term primary care physician means a physician who is identified in the available data as a general practitioner, family p ractice practitioner, general internist, or obstetrician or gynecologist.  1833(x)(2)(A)(i)  (I) is a physician (as described in section 1861(r)(1)) who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or   (II) is a nurse practitioner, clinical nurse specialist, or physician assistant (as those terms are defined in section 1861(aa)(5)).   C. Nationally Non -Covered Indications   1. Alcohol screening is non- covered when performed more than one time in a 12- month period.  2. Brief face -to-face behavioral counseling interventions are non- covered when performed more than once a day; that is, two counseling interventions on the same day are non- covered.   3. Brief face -to-face behavioral counseling interventions are non- covered when performed more than four times in a 12- month period  D. Other  Medicare coinsurance and Part B deductible are waived for this preventive service   (This NCD last reviewed October 2011.)   210.9  Screening for Depression in Adults (Effective October 14, 2011)  (Rev. 139, Issued: 11- 23-11, Effective: 10 -14-11, Implementation: 12- 27-11 non -shared system edits/04 -02-12 shared system edits/07- 02-12 CWF, HICR, MCS MCSDT)   A. General   Among persons older than 65 years, one in six suffers from depression.  Depression in older adults is estimated to occur in 25% of those with other illness including cancer, arthritis, stroke, chronic lung disease, and cardiovascular disease.  Other stress ful events, such as the loss of friends and loved ones, are also risk factors for depression.  Opportunities are missed to improve health outcomes when mental illness is under -recognized and under -treated in primary care settings.