In a study, published online by the journal Medical Care by researchers at Tufts Medical Center throws light on factors that affect Medicare Insurance decisions relating to payment for medical technologies. The study emphasizes that the Centers for Medicare and Medicaid Services (CMS) has integrated evidence-based medicine into its decision making, stressing the significance of the strength and quality of the supporting clinical evidence. Apart from this the study illustrates the importance of the accessibility of alternative therapies, while suggesting that CMS accounts for value in coverage decisions.

By law, Medicare Insurance is authorized only to cover medical technology considered “reasonable and necessary” for the diagnosis of illness or injury in Medicare beneficiaries. CMS makes 10-15 national coverage determinations (NCDs) each year on technologies considered to have a significant impact on the program. As CMS has not provided formal guidance on the explanation of the “reasonable and necessary” criteria, it has always been unclear as to what factors play a role in technology coverage decisions. This study is the first of its kind to evaluate quantitatively the factors behind Medicare decisions.

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