No more Alzheimer's catch-22: CMS calls for fair medicare coverage. (News Fronts).

THE CENTERS FOR MEDICARE AND MEDICAID Services (CMS) has issued a program memorandum calling for an end to discriminatory practices affecting Medicare coverage for people with Alzheimer's disease.

The Medicare Advocacy Project, a joint effort of the Alzheimer's Association and the American Bar Association Commission on Legal Problems of the Elderly, was instrumental in advocating for the new CMS policy.

According to Leslie Fried, director of the Medicare Advocacy Project, most people with Alzheimer's have been in a Catch-22 situation. Medical researchers and clinicians encourage early diagnosis of Alzheimer's to maximize the benefits of early intervention and treatment. But a primary diagnosis of Alzheimer's or dementia prompts some Medicare carriers and intermediaries to automatically restrict or deny access to physical, occupational, speech, and other therapies--services commonly covered by Medicare for patients without Alzheimer's.

"We were hearing from people around the country that Medicare was leaving [Alzheimer's patients] out in the cold," says Fried. "It was based on the theory that individuals with Alzheimer's disease can't learn, can't remember, can't develop relationships with therapists, and therefore cannot benefit."

Fried adds that nursing home residents with Alzheimer's were among those affected by the discriminatory practices, especially in the areas of rehabilitative therapies and mental health services.

The new CMS policy states that "a claim submitted with only the diagnosis of Alzheimer's disease may entitle a beneficiary to evaluation and management visits and therapies if a contractor determines that these therapies are reasonable and necessary when reviewed in the context of a beneficiary's overall medical conditions."

Providers will now be instructed to enter the primary diagnosis or condition along with the secondary diagnosis that most closely reflects the medical necessity of the services. When a Medicare beneficiary with dementia experiences a health problem unrelated to the dementia, the provider must submit a claim with a primary diagnosis that most accurately reflects the need for the provided service.

Fried says the new CMS policy will be an important first step in ending the discriminatory practices, but she adds that "for this policy to really make needed medical care available for people with Alzheimer's, insurance carriers and intermediaries must begin to implement the new ruling."