Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Marijuana for Medical Use
Policy #:MA00.038a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Marijuana for medical use is not covered by the Company because it is an item not covered by Medicare because the US Food and Drug Administration (FDA) has not approved marijuana for medical use. A drug must receive final approval from the FDA to be marketed for an approved diagnosis or condition. Therefore, medical marijuana is not eligible for reimbursement consideration.
Policy Guidelines

This policy is consistent with Medicare's coverage determination.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, marijuana for medical use is not eligible for payment under the medical benefits of the Company’s Medicare Advantage products because the service is not covered by Medicare.

Description

The US Food and Drug Administration (FDA) is responsible for the approval and marketing of drugs for medical use, including controlled substances.

For the purpose of this policy, the term marijuana refers to the dried leaves and flowers of Cannabis sativaplant, and any mixture or preparation thereof, and does not include FDA-approved drugs (e.g., dronabinol [Marinol] or nabilone [Cesamet]) that may contain active ingredients that are present in marijuana.

Medical use of marijuana refers to the use of marijuana (cannabis), including components of marijuana (cannabis) as a professional provider's recommended form of medicine or herbal therapy, often to treat individuals with chronic or terminal illnesses.
References

Company Benefit Contracts.

Harding A. Medical Marijuana. WebMD. Pain Management Health Center. [WebMD Web site.] 11/4/2013. Available at:
http://www.webmd.com/pain-management/features/medical-marijuana-uses. Accessed August 14, 2018.

National Institutes of Health (NIH). National Institute on Drug Abuse. Marijuana - Drug Facts. [NIH Web site].March 2016. Available at:
http://www.drugabuse.gov/publications/drugfacts/marijuana. Accessed August 14, 2018.

New Jersey Senate Bill 119, dated JANUARY 7, 2010. Available at: http://medicalmarijuana.procon.org/sourcefiles/NJS119.PDF. Accessed August 14, 2018.

Pennsylvania Senate Bill 3, dated JANUARY 26, 2015. Available at: http://www.legis.state.pa.us/CFDOCS/Legis/PN/Public/btCheck.cfm?txtType=PDF&sessYr=2015&sessInd=0&billBody=S&billTyp=B&billNbr=0003&pn=1690. Accessed August 14, 2018.

US Food and Drug Administration (FDA). U.S. Department of Health and Human Services. Researching the Potential Medical Benefits and Risk of Marijuana. [FDA web site]. 07/13/2016. Available at:
https://www.fda.gov/newsevents/testimony/ucm511057.htm. Accessed August 14, 2018.

US Food and Drug Administration (FDA). U.S. Department of Health and Human Services. FDA and Marijuana. [FDA website]. 02/09/2016. Available at:
http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm421163.htm. Accessed August 14, 2018.

US Food and Drug Administration (FDA). U.S. Department of Health and Human Services. FDA and Marijuana: Questions and Answers. [FDA website]. 09/30/2015. Available at: http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm421168.htm. Accessed August 14, 2018.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

MA00.038a
10/09/2019This policy has been reissued in accordance with the Company's annual review process.
09/26/2018This policy has been reissued in accordance with the Company's annual review process.
06/07/2017This policy has been reissued in accordance with the Company's annual review process.
03/09/2016Marijuana for medical use remains not covered and not eligible for reimbursement consideration by the Company.

MA00.038
01/01/2015This is a new policy.




Version Effective Date: 03/23/2016
Version Issued Date: 03/23/2016
Version Reissued Date: 10/10/2019