Medicare To Cover New Services For Elderly

The Centers for Medicare & Medicaid Services (CMS) announced recently that it intends to cover eye treatments for those with age-related macular degeneration, foot care coverage for some beneficiaries with diabetes, and ambulatory blood pressure monitoring for some patients.

Treatment Of Eye Disease Affecting Elderly
CMS intends to expand the treatment options available for Medicare beneficiaries with age-related macular degeneration, the leading cause of blindness in older Americans.

New Medicare coverage policy will expand coverage of ocular photodynamic therapy with verteporfin for this eye disease. Approximately 35,000 to 70,000 beneficiaries will be affected by this new policy, tripling the number helped by this treatment.

"By expanding access to this important new treatment, we are improving the quality of life for many Medicare beneficiaries, " said HHS Secretary Tommy G. Thompson.

Last year, CMS announced coverage of this therapy for patients with "classic" lesions. This decision extends it to those with "occult" lesions. Occult lesions are less well defined and more difficult to detect than classic lesions.

CMS re-examined its coverage decision at the request of The Vitreous Society, an organizations of physicians specializing in diseases of the retina.

Age-related macular degeneration (AMD) involves the deterioration of the central region of the retina called the macula, which results in a severe and irreversible loss of central vision. The National Institutes of Health estimate that nearly 1.7 million elderly Americans, 5 percent of the total population over 65 years of age, have some degree of vision loss due to AMD.

The underlying cause of AMD is not well understood, but population-based studies have found several risk factors for the disease in addition to old age, including family history of AMD, low dietary intake or plasma concentrations of antioxidant vitamins and zinc, and cigarette smoking. AMD has also been found to occur more frequently in Caucasians.

The form of the disease known as "wet" AMD results from the abnormal growth of blood vessels, a process known as choroidal neovascularization, which leak fluid under the macula, causing the formation of CNV lesions which result in a sudden and severe loss of central vision. The wet form of AMD accounts for the vast majority of cases of severe blindness.

Ocular Photodynamic Therapy (OPT), which is exclusively used in patients with wet AMD, involves the infusion of a light activated drug called verteporfin. Infusion of verteporfin is followed by the use of a non-thermal laser. Upon application of this laser, verteporfin becomes active and begins treating the adjacent lesions, resulting in the temporary closure of leaking blood vessels.

Details of the Decision Memorandum announced today can be found at www.hcfa.gov/coverage/8b3-ee.htm.

Foot Care Coverage For Some Beneficiaries With Diabetes
CMS will make it easier for beneficiaries suffering from diabetic peripheral neuropathy with loss of protective sensation (LOPS) to receive regular foot care.

Studies link diabetic peripheral neuropathy to increased risk for foot ulcers and amputations. This disease is a nerve condition that inhibits many diabetics' ability to feel the pain that might alert them to potentially dangerous injury. Regular foot care can help avoid injury and infection.

"A minor injury or infection that could be treated routinely for most patients can cause severe problems, even leading to amputation, for people with diabetes," Health and Human Services Secretary Tommy G. Thompson said. "By covering regular foot care for those of high risk of foot ulcers, Medicare will help many beneficiaries avoid potentially dangerous complications."

Beneficiaries may receive two foot exams per year, specifically for diabetic peripheral neuropathy with LOPS, provided they have not seen a foot care professional for some other reason.

Medicare law excludes coverage for routine foot care, except under specific circumstances, such as the treatment of a localized illness of the feet as in the case of diabetic peripheral neuropathy with LOPS.

The new decision memorandum is consistent with other Department of Health and Human Services initiatives to reduce the rate of amputations in people with diabetes, such as Healthy People 2010 and Peer Review Organization initiatives to increase diabetic foot awareness among primary care physicians.

CMS reviewed its existing policy on foot care related to diabetic peripheral neuropathy with LOPS at the request of the American Diabetes Association, and decided to approve the expanded coverage after a careful review of scientific data. CMS will announce when the coverage policy will become effective.

"Diabetes affects millions of older Americans, who will benefit greatly from this expanded coverage," said Jeffrey Kang, MD, MPH, director of CMS' Office of Clinical Standards and Quality and the agency's chief clinical officer. "This newest Medicare coverage decision illustrates our determination to improve the care given to Medicare beneficiaries by basing coverage decisions on the best available scientific evidence.

Details of the Decision Memorandum announced can be found at www.hcfa.gov/coverage/8b3-o.htm.

Ambulatory Blood Pressure Monitoring For Some Patients

CMS intends to expand diagnostic options for Medicare beneficiaries by making ambulatory blood pressure monitoring (ABPM) available to patients with suspected white coat hypertension.

Some people have high blood pressure in a physician's office, perhaps a response to the anxiety of being in the doctor's office, symbolized by the physician's white coat, and have normal blood pressure outside the office. Knowing if the patient actually is hypertensive or merely reacting to the office environment enables the physician to better manage the patient's care.

"Making modern medical technology available means better health care for Medicare beneficiaries," said HHS Secretary Tommy G. Thompson.

Ambulatory blood pressure monitoring (ABPM) is a method of blood pressure measurement that is done outside the doctor's office. The patient wears a blood pressure cuff over a 24-hour period, which automatically takes the patient's blood pressure at fixed times throughout the period. The readings are stored in the device and later interpreted at the physician's office.

Prior to the effective date of this national coverage determination, ambulatory blood pressure monitors were non-covered by Medicare. CMS received a formal request from a manufacturer of the monitoring devices for a new national coverage determination providing coverage.

CMS was asked to cover ABPM for five specific conditions. However, only one of these conditions, suspected white coat hypertension, had scientific evidence to support it. A review of 31 studies, in addition to a number of position and consensus statements from professional societies, demonstrated that ABPM can provide useful information to a physician to determine whether a patient is truly hypertensive or merely exhibiting white coat hypertension. CMS will announce when the coverage policy will become effective.

Details of the decision memorandum announced can be found at www.hcfa.gov/coverage/8b3-ff.htm.