CMS memos - Intensive Behavioral Therapy for Cardiovascular Disease and STIs

The Centers for Medicare and Medicaid Services (CMS) has determined that the evidence is adequate to conclude that intensive behavioral therapy for cardiovascular disease (CVD) is reasonable and necessary for the prevention or early detection of illness or disability, is appropriate for individuals entitled to benefits under Part A or enrolled under Part B and is comprised of components that are recommended with a grade of A or B by the U.S. Preventive Services Task Force (USPSTF).

Intensive behavioral therapy for cardiovascular disease (referred to below as a CVD risk reduction visit) consists of the following three components:

encouraging aspirin use for the primary prevention of cardiovascular disease when the benefits outweigh the risks for men age 45-79 years and women 55-79 years;
screening for high blood pressure in adults age 18 years and older; and
intensive behavioral counseling to promote a healthy diet for adults with hyperlipidemia, hypertension, advancing age and other known risk factors for cardiovascular and diet-related chronic disease.

CMS notes that only a small proportion (about 4%) of the Medicare population is under 45 years (men) or 55 years (women), therefore the vast majority of beneficiaries should receive all three components. Intensive behavioral counseling to promote a healthy diet is broadly recommended to cover close to 100% of the population due to the prevalence of known risk factors.

Therefore, CMS will cover one face-to-face CVD risk reduction visit each year for Medicare beneficiaries:

who are competent and alert at the time that counseling is provided; and whose counseling is furnished by a qualified primary care physician or other primary care practitioner and in a primary care setting.

The behavioral counseling intervention for aspirin use and healthy diet should be consistent with the Five As approach that has been adopted by the USPSTF to describe such services:

Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.
Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.
Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.
Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

For the purposes of this decision memorandum, a primary care setting is defined as one in which there is provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities and hospices are not considered primary care settings under this definition.

Fore more information, visit the CMS website.

The Centers for Medicare & Medicaid Services (CMS) has also determined the following:

The evidence is adequate to conclude that screening for chlamydia, gonorrhea, syphilis and hepatitis B, as well as high intensity behavioral counseling (HIBC) to prevent STIs, consistent with the grade A and B recommendations by the U.S. Preventive Services Task Force (USPSTF), is reasonable and necessary for the prevention or early detection of an illness or disability and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B.

Therefore, CMS will cover screening for these USPSTF indicated STIs with the appropriate FDA approved/cleared laboratory tests, used consistent with FDA approved labeling and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations, when ordered by the primary care physician or practitioner, and performed by an eligible Medicare provider for these services.

Read specifics about screening for STIs on the CMS website.