Marrow and cord blood transplants can be used to successfully treat more than 70 diseases. Often transplant is a patient’s only hope for a cure. While commercial insurance covers transplant for most, if not all, diseases, the Medicare program does not. This means that if someone develops a disease or condition when 65 or older, or on long-term or permanent disability, he or she may not have access to a life-saving transplant.
Be The Match, in partnership with the American Society for Blood and Marrow Transplant (ASBMT), is working closely with the Centers for Medicare and Medicaid Services (CMS) to provide Medicare beneficiaries with access to a life-saving transplant for more diseases. Currently, Medicare only covers transplants for the following diseases:
- Leukemia, leukemia in remission or aplastic anemia when it is reasonable and necessary
- Severe combined immunodeficiency disease (SCID) and Wiskott-Aldrich syndrome
- Myelodysplastic Syndromes (MDS), if it meets criteria for Coverage with Evidence Determination (CED), which requires data collection of a Medicare-approved, prospective clinical study.
We have made important progress to expand this coverage in recent months. As a result of our efforts, CMS is considering coverage for three new diseases:
- Sickle Cell Disease
- Multiple Myeloma
Similar to MDS, coverage for these diseases may also require a Medicare-approved, prospective clinical trial. This is called CED. CED would allow individuals with sickle cell disease, myelofibrosis and multiple myeloma to receive a transplant while CMS gathers data on the outcome of transplant for these diseases. Once enough data is gathered to show transplant effectively treats these diseases, CMS may establish a National Coverage Determination (NCD). This means Medicare would now cover transplant for these three diseases without requiring enrollment in a clinical trial.
CMS is currently considering how to design a study for these three diseases. Be The Match and ASBMT are working closely with CMS to make sure the study requirements do not create unnecessary barriers for patients.
Establishing clear coverage rules is important to protect access to life-saving transplants. Medicare is silent on whether it will cover marrow or cord blood transplant for all other diseases that are not specifically listed as covered. Because Medicare will not tell hospitals upfront if it will cover transplants for most diseases, hospitals may not be able to move forward with the transplant due to the uncertainty. This creates a barrier for patients who need a marrow transplant to cure their disease.
Be The Match and ASBMT will continue efforts to expand access to transplant for the Medicare population. We will need your help as well, so please stay tuned for further developments.