Medicare's Listed Preventive Services at SSA 1861 and Open-Ended UPSTF Option

Medicare has enumerated benefits (health benefits defined; preventive benefits defined) at SSA 1861.

For example, the Act covers "medical and other health services," of which 1861(s)(1) are "physician services," 1861(s)(1)(2)(B) are "hospital services incident to a physician" (e.g. hospital surgicenters and ERs).  1861(s)(2)(J) covered prescription services for transplants before there was a Medicare Part D benefit. 

Then you get a handful of screening services, like mammography, PSA testing, colonoscopy, PAP smears, and some others.  For example, 1861(s)(2)(P) covers "prostate screening services" as defined at "subsection (oo)" and so on.  It goes on for pages.

Some Preventive Services Are Easier to Add Than Others

One take home lesson from reading 1861 carefully is that new modalities for prostate and colorectal screening can be added by CMS (probably via an NCD), whereas outside that, any kind of other preventive services can be added IF and AFTER the service is approved by USPSTF. 

For example, liver cancer screening or ovarian cancer screening would have to be approved first by USPSTF. 

(One other pathway, hypothetically, would be a demo program to screen for something under the Innovation Center (CMMI).)

Examples of Statutory Definitions of Some Preventive Benefits

Prostate Screening
Defined at subsection (oo) as a test for early detection of prostate cancer in a man over 50, to include DRE, and PSA, and "such other procedures as the Secretary finds appropriate" including for effectiveness, costs, and other factors the Secretary finds appropriate.  (Note: cost effectiveness clause here at (oo).)

Colorectal Screening
Defined at (pp) to include fecal occult blood test, sigmoidoscopy, colonoscopy, and "such other tests or procedures as the Secretary determines appropriate, in consultation with appropriate organizations."    (Note: no cost effectiveness clause here at (pp).)

Bone Mass Measurement
Defined at (rr) as "radiologic or radioisotopic procedure or other procedure" approved by FDA for the purpose of identifying bone mass or detecting bone loss or determining bone quality.   There are exactly five indications, estrogen-deficient woman, vertebral anomalies, steroid therapy, hyperparathyroidism, and osteoporosis drug therapy.

Cardiovascular Blood Test
Defined at (xx) as cholesterol and other lipid/triglyceride levels, May include other indications and blood tests if approved by USPSTF.

Additional Services Added by NCD After USPSTF Approves

After the enumerated services (above just a sample), additional services at (ddd) can be added IF:

• Reasonable and necessary to prevent or early detect an illness or disability AND
• Recommended A/B by USPSTF, AND
• Appropriate for persons in Part A or B, AND
• Determination made by NCD process.

If CMS does look at a USPSTF benefit, and consider converting it via an NCD to a Medicare benefit, CMS can consider cost effectiveness.  We read under the USPSTF clause, "The Secretary may conduct an assessment of the relation between predicted outcomes and the expenditures for such service and may take into account the results of such assessment in making such determination."

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The Colorectal NCD.   The Colorectal NCD has been revisited three times under 1861(pp):

1. To add the FIT test, 
2. To non-cover virtual CT colonography, and 
3. To cover the Exact Science Cologuard test.  
1. These are each under NCD 210.3, here.

Claims and Codes for Preventive Services

Medicare has a special Claims Processing Manual (rulebook) for preventive services, Claims Processing Manual, Chapter 13, here.   For CRC, codes include 82270 (Guaiac), G0328 (FIT), Cologuard 81528 (temp code had been G0464).. 

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Gray Areas.

There are some gray areas.  For example, Medicare has a smoking cessation benefit, and USPSTF has a preventive service Smoking Cessation that it approved.  However, these two things do not interact.   Medicare approved the Smoking Cessation Benefit in 2005 via an NCD, ruling that for smokers, smoking cessation was simply part of necessary medical care.   USPSTF also has a preventive category benefit called Smoking Cessation.  Today it could be the basis of the NCD, but in 2005 the NCD stood by itself as a "necessary medical benefit"  and was not linked to USPSTF or prevention.

I believe when CMS created the Smoking Cessation benefit in 2005, it was classed as "medical care" and therefore had a 20% copay, but a later law said that USPSTF-covered services have no copay at Medicare, so I suspect today it is also classified as a no-copay service since it is also endorsed by USPSTF.

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All this may add up to a more complex system for preventive services in Medicare than in private healthcare or in some other countries.  E.g. an OncImmune test for high risk lung cancer screening might have a faster path in the UK than USA; see here.