Medicare proposes coverage of ‘breakthough’ medical devices

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CMS is proposing for Medicare to cover all medical devices designated by the Food and Drug Administration as breakthrough devices.

The proposed rule, released Monday, is in response to a Trump administration executive order from late 2019 that tasked CMS with streamlining coverage for breakthrough medical devices. Manufacturers can voluntarily participate in FDA’s Breakthrough Devices Program to secure quicker review of their devices. The program is only open to devices that provide effective treatment or diagnosis of a life-threatening or debilitating condition and they must use a breakthrough technology, offer significant advantages compared to existing alternatives or have no approved clearance currently in existence.

Medicare currently doesn’t cover breakthrough devices. Under the proposed rule, Medicare will cover the use of a breakthrough device for four years after it receives FDA market authorization. CMS said it believes four years is enough time to “encourage” device makers to voluntarily study how the device impacts Medicare beneficiaries, although it’s not required. After the four years, manufacturers will have access to all the usual coverage options available including Medicare’s national coverage determination process, according to the agency.

Devicemakers must notify CMS if they are interested in the program, which is called the Medicare Coverage of Innovative Technology pathway. Only devices that fit under a Medicare benefit can be covered; some wearable devices aren’t covered by Medicare.

Medical Device Manufacturers Association CEO Mark Leahey on Monday applauded the proposal and noted his organization has advocated for these kinds of policies.

“We look forward to continue working with CMS, the administration, Congress and all stakeholders to narrow the gap between regulatory and reimbursement decisions that will bolster patient care,” he said in a statement

The proposed rule also would changeCMS’ standards for coverage determinations. Currently, CMS considers if a medical device should be covered by reviewing if it’s safe and effective. CMS wants to add another standard, called appropriate for Medicare patients, to determine coverage. This would allow CMS to determine a device’s Medicare eligibility by seeing if it’s already covered by commercial insurance.

CMS is seeking public comments on the proposed rule until Nov. 2. The agency is specifically asking for feedback from stakeholders on the four-year duration of the Medicare Coverage of Innovative Technology pathway, if what’s covered should be expanded and the proposed changes to the “reasonable and necessary” standards.

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