Scrutiny of Common Interventional Pain Procedures Possible as Part of Medicare National Coverage Decision Process

The Centers for Medicare & Medicaid Services (CMS) has announced its annual potential National Coverage Decision (NCD) topics – a process whereby the agency reviews the appropriateness of current coverage decisions.  Included in a list of 32 potential NCD topics is Medicare's coverage for epidural and transforaminal injections.  

This CMS process is used to determine if an item or service meets a reasonable and necessary standard for coverage as described in Medicare statute. The process for review may be initiated by public input about misused, overused, or underused services or by CMS staff request. 

If an NCD review is initiated, CMS may refer the issue to the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC), a Committee comprised of representatives from the health care community including physician specialists, public health administrators and advocates for patients and other related fields.  CMS often utilizes the Agency for Healthcare Research and Quality (AHRQ) to perform a technological assessment of referred topics. 

At the conclusion of the process, CMS publishes a draft decision, which begins a 30 day public comment period.  The comment period is followed by a 60 day requirement for the issuance of a decision memorandum and implementation instructions.  Any NCD may be tailored to address specific clinical information.  Decisions may also be modified at any time to reflect new clinical information. 

CMS does not review all its potential NCD topics.  It is not anticipated that CMS will review all 32 announced potential topics.  Historically, approximately ten decisions are issued per year.  In contrast, Medicare Contractor Local Coverage Determinations (as established by local Medicare contractors for their local jurisdictions) are far more frequent, ranging in the hundreds per year. ASA is closely monitoring this situation and will inform members of any developments.

Review the Medicare National Coverage Process Flow Chart.
Review the Potential National Coverage Decision Topics.
Learn more about Medicare Coverage Determination.