ASH Creates Model Policy for Local Medicare Carriers on MDS

As you may be aware, ASH was successful in removing any limitation on erythropoiesis-stimulating agent (ESA) treatment for anemia in patients with myelodysplastic syndromes (MDS) from Medicare's National Coverage Decision (NCD) on ESAs in cancer. Unfortunately, CMS directed that ESA coverage for MDS patients be handled on the local level and several Medicare carriers and Medicare Administrative Contractors (MACs) are in the process of revising their ESA coverage limitations for MDS patients. Also, some of these local policies reflect the limitations that are included in the NCD.

To assist its members on the local level, ASH, working with a task force with expertise in MDS, developed a model policy on coverage for ESA treatment of anemia for patients with MDS. It is written in a format used for local coverage decisions (LCDs). We encourage you to submit this document along with a personal letter to your carrier if your local policy is being revised and is open for comment. ASH will submit the model policy formally as part of the open request for comments, but the local carriers and MACs are typically more sympathetic to local physicians.

There currently are two draft LCD policies that are open for comment until early December: Trailblazer, which will cover Delaware, Maryland, Texas, and Virginia (and likely Colorado, New Mexico and Oklahoma) and Noridian, which will cover Arizona, Montana, North Dakota, South Dakota, Utah, and Wyoming.

(Note - The revisions to ESA coverage on the local level are occurring at the same time reforms are being made to the existing carrier structure. For that reason, which states are covered by which policy is very fluid.)

Please contact Government Relations and Practice Specialist Stephanie Kart (skart@hematology.org or 202-776-0544) if you would like to learn more about carrier reforms, including the status of the ESA coverage policy, in your state and for assistance in working with local carriers.

ASH Model Policy for Local Medicare Carriers on MDS