When is it NOT medically necessary to prevent illness? And other Medicare coverage questions for CMS
If you read my post last Wednesday, you now know that the shingles vaccine is covered under the Medicare Part D program. What I neglected to tell you—and what I only recently found out after spending a few hours trying to decipher the doublespeak in the voluminous “Medicare & You” handbook—is that there is a very complicated caveat: Your doctor may need to show that the vaccine is “medically necessary” before your prescription drug plan will cover it.
Yep, there it is, buried on page 93, the only single reference to the shingles vaccine in the entire 148-page “handbook”:
Except for vaccines covered under Part B, Medicare drug plans must cover all commercially-available vaccines (like the shingles vaccine) when medically necessary to prevent illness.
The entire sentence is confusing enough, but what exactly does “medically necessary” mean? I wasn’t sure, so I turned to the “Definitions” in Section 8 and read as follows:
Medically Necessary—Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice.
OK, but the shingles vaccine prevents a very painful medical condition from occurring in the first place, so it precludes the need for a diagnosis or treatment! Does this mean that a preventive vaccine would never fall under the “medically necessary” category, and therefore, never be covered by Part D?
Now I was getting annoyed, so I decided to call Medicare directly and get an answer.
After weeding through the automated phone system to get an actual person, a very pleasant-sounding gentleman (Jeff Dean) came to the phone. I told him that I was calling on behalf of everyone who has Medicare and is confused about the shingles vaccine. Here is how Jeff explained it to me:
If you are enrolled in a Part D plan you should find out if the plan covers the vaccine. Some plans may require a prior authorization, which means your doctor must contact the drug plan before you can get the vaccine. Your doctor may need to show that the drug is medically necessary for the plan to cover it—in other words, the doctor must determine that you need it because you are at risk or maybe because you had a shingles outbreak before.
A better example, Jeff explained, is the tetanus vaccine: If you just want to get the tetanus vaccine for the sake of prevention, Medicare will not cover it. However, if you step on a nail while gardening and your doctor orders a tetanus vaccine, it will be covered because it is now considered treatment for a condition (an injured foot).
My next step was to find out just who could be “at risk” for shingles. According to numerous clinical sources, including the Mayo Clinic, anyone who has ever had chickenpox is at risk for developing shingles. Most adults in the United States had chickenpox when they were children, so just about every adult is at risk for shingles! (The vaccine for chicken pox didn’t come to the U.S. until 1995.) The risk also increases with age and is higher in people with compromised immune systems due to diseases such as HIV/AIDS; cancer treatment; or certain medications used to prevent rejection of transplanted organs.
Some important questions for CMS
So now that I have gotten to the bottom of this issue, I have some questions for the Centers for Medicare & Medicaid Services:
1. When is it NOT medically necessary to prevent illness? (Is illness not a medical condition that should be prevented when possible?)
2. Wouldn’t it be better for everyone in the long run—especially seniors—if Medicare and prescription drug plans paid $100 to help prevent this painful condition rather than $500 or more later on to treat it?
3. Under the Patient Protection and Affordable Care Act, millions of Medicare beneficiaries now have access to many free preventive services, including an annual flu shot, pneumonia vaccine, and hepatitis B vaccine. Since, theoretically, all adults are at risk of getting shingles, shouldn’t this vaccine also be added to the list?
I have many more questions for CMS — such as, When does a book become so big that it can no longer be called a “handbook”? — but I’ll wait until another time to rant more.