Providers may not be certain how Gateway Health Plan Medicare Assured® uses the Medicare National Coverage Determinations (NCDs) and Local Carrier Coverage Determinations (LCDs), which are available on the Medicare website at www.cms.hhs.gov/mcd/search.asp.
Gateway Health Plan Medicare Assured® adheres to coverage decisions outlined in a NCD. If a certain procedure is determined to be non-covered, Gateway will not cover the procedure. For example, Medicare has determined that bariatric surgery is a covered benefit, but an open adjustable gastric banding is non-covered. Likewise, Gateway does not cover an open adjustable gastric banding.
Medicare Local Carriers issue LCDs based on geographic region, and Gateway follows the appropriate LCDs based on the member’s geographic region. For example, a LCD titled Botulinum Toxin Type A and B (L27476) states that the clinical efficacy of botulinum toxin in the treatment of chronic headaches and intractable headache has not been proven and is not medically necessary. Since it is not medically necessary, the treatment would not be covered by Medicare, nor is it covered by Gateway.
Please note that some LCDs provide guidance on submitting medical records to carriers in order to obtain payment. Please note that instructions on how to obtain an authorization from Gateway for services that require prior authorization, or instructions for how to file a provider appeal with Gateway may be located in the Provider Manual, www.gatewayhealthplan.com or in a copy of your recent Gateway provider agreement.
It is important to note that Gateway Health Plan Medicare Assured® does cover additional benefits/services that are not covered under Medicare, such as eyeglasses and hearing aid benefits. These extra benefits are updated annually and are outlined in the member’s annual Evidence of Coverage, located in the Provider Manual and on www.gatewayhealthplan.com.