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MIR-2006-7AB, July 2006
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Pancreas Transplants Alone (PA)
Provider Types Affected
Physicians and providers billing Medicare fiscal intermediaries (FIs) and carriers for PA
Background
Medicare covers whole organ pancreas transplant-tation when it is performed in conjunction with or after kidney transplantation (National Coverage Determination (NCD) Manual, Section 260.3). However, Medicare does not cover PA in diabetes patients without end-stage renal failure because of a lack of sufficient evidence, based in large part on a 1994 Office of Health Technology Assessment report.
Key Points
This article is based on information contained in Change Request (CR) 5093, which informs physicians and providers that, effective for services performed on or after April 26, 2006, Medicare will cover PA for beneficiaries in the following limited circumstances:
- Facilities must be Medicare-approved for kidney transplantation (Approved centers are found at http://www.cms.hhs.gov/ESRDGeneralInformation/02_Data.asp#TopOfPage on the CMS Web site).
- Patients must have a diagnosis of Type I
diabetes:
- The patient with diabetes must be beta cell autoantibody positive; or
- The patient must demonstrate insulinopenia, defined as a fasting C-peptide level that is less than or equal to 110 percent of the lower limit of normal of the laboratory’s measurement method. Fasting C-peptide levels will be considered valid only with a concurrently obtained fasting glucose <225 mg/dL.
- Patients must have a history of medically-uncontrollable labile (brittle) insulin-dependent diabetes mellitus with documented recurrent, severe, acutely life-threatening metabolic complications that require hospitalization.
- These complications include frequent hypoglycemia unawareness or recurring severe ketoacidosis, or recurring severe hypoglycemic attacks.
- Patients must have been optimally and intensively managed by an endocrinologist for at least 12 months with the most medically recognized advanced insulin formulations and delivery systems.
- Patients must have the emotional and mental capacity to understand the significant risks associated with surgery and to effectively manage the lifelong need for immunosuppression.
- Patients must otherwise be suitable candidates for transplantation.
Billing and Claims Processing
- The following ICD-9-CM codes will be recognized by FIs and carriers for pancreas transplantation alone for beneficiaries with Type I diabetes when billed with HCPCS 48554:
- Carriers and FIs who receive claims for PA services that were performed in an unapproved facility should use the following messages upon the reject or denial:
- Medicare Summary Notice MSN Message - MSN code 16.2 (This service cannot be paid when provided in this location/facility)
- Remittance Advice Message - Claim Adjustment Reason Code 58 (Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service)
· Carriers and FIs who receive claims for PA services that are not billed using the covered diagnosis/procedure codes listed above should use the following messages upon the reject or denial:
· Modification of the current coverage policy on pancreas transplants can be found in Publication 100-03, Section 260.3 and claims processing information is located in Publication 100-04, Chapter 3, Section 90.5.1. The location of this information is listed in the Additional Information section of this article.
| Note: Carriers and FIs will hold any PA claims with dates of service on or after April 26, 2006, until the claims can be processed in their systems. For FIs this date is October 2, 2006, and for carriers the date is July 3, 2006. |
Implementation
The implementation date for this instruction is no later than:
- July 3, 2006 for carriers; and
- October 2, 2006 for FIs.
Additional Information
The official instructions issued to your Medicare FI or carrier regarding this change can be found at http://www.cms.hhs.gov/Transmittals/downloads/R56NCD.pdf for the NCD manual revision and http://www.cms.hhs.gov/Transmittals/downloads/R957CP.pdf  for changes to the Medicare Claims Processing Manual.
If you have questions, please contact your Medicare FI or carrier at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
MLN Matters Number: MM5093
Pub. 100-3, Transmittal# R56NCD, CR# 5093
Pub. 100-4, Transmittal# R957CP, CR# 5093
Related CR Release Date: May 19, 2006
Effective Date: April 26, 2006
Implementation Date: July 3, 2006 for carriers; October 2, 2006 for FIs
Attention Physicians, Hospitals, and ESRD Facilities!
Sign up now for the Physicians-L, Hospitals-Acute-L, or ESRD-L listservs at http://www.cms.hhs.gov/apps/mailinglists/.  Get your Medicare news as it happens!
Additional Information Provided by Empire Medicare Services (Part B)
Important Billing Information
Providers are encouraged to hold PA claims for dates of service April 26, 2006 and after until July 3, 2006, when contractor claims processing systems are developed to accept and pay these claims.
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