ASH Supports Request by ASBMT and NMDP to Expand Medicare Coverage for Stem Cell Transplant

In online comments submitted to the Center for Medicare and Medicaid Services (CMS) on May 30 2015, the American Society of Hematology (ASH) strongly supported the request jointly made by the American Society for Blood and Marrow Transplant (ASBMT) and the National Marrow Donor Program (NMDP) to expand the coverage indications for the use of hematopoietic stem cell transplant for patients covered by Medicare.

Under the current coverage determination, some conditions such as leukemia and aplastic anemia are explicitly covered for Medicare patients. Some conditions, such as myelodysplastic syndromes, are covered under a policy called Coverage with Evidence Development (CED) which allows for Medicare coverage in exchange for the provision of certain clinical data. CMS also names specific non-covered conditions such as solid tumors.

For all conditions not named explicitly, coverage determinations revert to the contractors that administer regional Medicare payment known as Medicare Administrative Contractors (MACs). Those organizations, in turn, may create their own local coverage determination policies or defer to a more general medical necessity policy.

The request that ASH supported aims to move three conditions from the category of not being named at all into the category of being covered nationwide – sickle cell disease, myelofibrosis, and lymphoma. It also requests that one condition that is named as non-covered, multiple myeloma, be removed from that category. ASH supported these changes due to the wealth of evidence presented by the two organizations in addition to the strong data collection efforts that are part of stem cell transplant.

The coverage determination process is a multi-step process that allows for a number of stages of public comment. Following this initial request for public comments, CMS will likely release a proposed change to the coverage determination which ASH hopes will reflect the requests made. CMS may also convene a national expert committee to review the coverage determination if it sees fit, although this has been used less and less in recent years. A final coverage determination, accounting for all public steps, would unlikely to be implemented until the late fall of 2015.