Private payers disagree with Medicare over medical device coverage about half the time

Health Aff (Millwood). 2015 Aug;34(8):1376-82. doi: 10.1377/hlthaff.2015.0133.


There are multiple payers in the US health care system, each making its own coverage determinations for medical technologies. For each of the forty-seven medical devices considered in national coverage determinations (NCDs) of the Centers for Medicare and Medicaid Services (CMS) issued between February 1999 and August 2013, we compared CMS's coverage policy with the policies issued by the largest sixteen private payers that made their decisions publicly available. Overall, we found that NCDs were equivalent to the corresponding private payer policies roughly half of the time, more restrictive approximately a quarter of the time, and less restrictive about a quarter of the time. Our findings indicate that patients may have variable access to medical technology across Medicare and private plans. They also suggest that private plans do not necessarily follow CMS's lead in making coverage decisions.

Keywords: Access To Care; Medical technology; Medicare.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Equipment and Supplies / economics*
  • Humans
  • Insurance Claim Review / organization & administration*
  • Insurance Coverage*
  • Insurance, Health / economics*
  • Insurance, Health / organization & administration*
  • Medicare / economics*
  • Organizational Policy
  • United States