CMS Pub. 100-03, ch. 1, § 200.3

Alzheimer’s Disease (AD)

(Rev.: 11692, Issued:11-09-22, Effective: 04-07-22, Implementation: 12-12-22)

A. General

Alzheimer’s disease (AD) is a currently irreversible brain disorder that progressively degrades memory,

cognitive function, and ability to carry out tasks of daily living. AD is the number one cause of dementia in

older Americans.

Antiamyloid-beta monoclonal antibodies (antiamyloid mAbs) are laboratory-made proteins designed to bind

a specific substance in the body, with the goal of marking it for destruction by the body’s immune

system. Scientists design various mAbs as treatments with the goal of targeting and neutralizing or clearing

infections (like the COVID-19 virus), cancer cells, and in the case of AD, amyloid accumulation in the brain.

B. Nationally Covered Indications

Effective April 7, 2022, the Centers for Medicare & Medicaid Services (CMS) covers Food and Drug

Administration (FDA) approved monoclonal antibodies directed against amyloid for the treatment of AD

when furnished in accordance with Section B under coverage with evidence development (CED) for patients

who have a clinical diagnosis of mild cognitive impairment (MCI) due to AD or mild AD dementia, both

with confirmed presence of amyloid beta pathology consistent with AD.

Coverage Criteria:

1) Monoclonal antibodies directed against amyloid that are approved by the FDA for the treatment of AD

based upon evidence of efficacy from a change in a surrogate endpoint (e.g., amyloid reduction) considered

as reasonably likely to predict clinical benefit may be covered in a randomized controlled trial conducted

under an investigational new drug (IND) application.

2) Monoclonal antibodies directed against amyloid that are approved by the FDA for the treatment of AD

based upon evidence of efficacy from a direct measure of clinical benefit may be covered in CMS-approved

prospective comparative studies. Study data for CMS-approved prospective comparative studies may be

collected in a registry.

3) For CMS-approved studies, the protocol, including the analysis plan, must include:

a. A study population whose diversity of patients are representative of the national population with MCI

due to AD or mild AD dementia.

b. A neurocognitive evaluation and a description of the instruments used to assess cognition and

function for the clinical diagnosis of MCI due to AD or mild AD dementia for study enrollment and

outcomes assessment.

c. A description of:

i. The multidisciplinary dementia team and optimal medical management.

ii. Study sites with clinical expertise and infrastructure to provide treatments consistent with the

safety monitoring outlined in the FDA-approved label.

4) CMS-approved studies of a monoclonal antibody directed against amyloid (antiamyloid mAb) approved

by the FDA for the treatment of AD based upon evidence of efficacy from a direct measure of clinical

benefit must address all of the questions below:

a. Does the antiamyloid mAb meaningfully improve health outcomes (i.e., slow the decline of cognition and

function) for patients in broad community practice?

b. Do benefits, and harms such as brain hemorrhage and edema, associated with use of the antiamyloid

mAb, depend on characteristics of patients, treating clinicians, and settings?

c. How do the benefits and harms change over time?

5) CMS-approved studies must adhere to the following standards of scientific integrity that have been

identified by the Agency for Healthcare Research and Quality (AHRQ):

a. The principal purpose of the study is to test whether the item or service meaningfully improves health

outcomes of affected beneficiaries who are represented by the enrolled subjects.

b. The rationale for the study is well supported by available scientific and medical evidence.

c. The study results are not anticipated to unjustifiably duplicate existing knowledge.

d. The study design is methodologically appropriate and the anticipated number of enrolled subjects is

sufficient to answer the research question(s) being asked in the National Coverage Determination (NCD).

e. The study is sponsored by an organization or individual capable of completing it successfully.

f. The research study is in compliance with all applicable Federal regulations concerning the protection of

human subjects found in the Code of Federal Regulations (CFR) at 45 CFR Part 46. If a study is regulated

by the FDA, it is also in compliance with 21 CFR Parts 50 and 56. In addition, to further enhance the

protection of human subjects in studies conducted under CED, the study must provide and obtain

meaningful informed consent from patients regarding the risks associated with the study items and/or

services, and the use and eventual disposition of the collected data.

g. All aspects of the study are conducted according to appropriate standards of scientific integrity.

h. The study has a written protocol that clearly demonstrates adherence to the standards listed here as

Medicare requirements.

i. The study is not designed to exclusively test toxicity or disease pathophysiology in healthy individuals.

Such studies may meet this requirement only if the disease or condition being studied is life threatening

as defined in 21 CFR §312.81(a) and the patient has no other viable treatment options.

j. The clinical research studies and registries are registered on the www.ClinicalTrials.gov website by the

principal sponsor/investigator prior to the enrollment of the first study subject. Registries are also

registered in the AHRQ Registry of Patient Registries (RoPR).

k. The research study protocol specifies the method and timing of public release of all prespecified

outcomes to be measured including release of outcomes if outcomes are negative or study is terminated

early. The results must be made public within 12 months of the study’s primary completion date, which is

the date the final subject had final data collection for the primary endpoint, even if the trial does not

achieve its primary aim. The results must include number started/completed, summary results for primary

and secondary outcome measures, statistical analyses, and adverse events. Final results must be reported

in a publicly accessible manner; either in a peer-reviewed scientific journal (in print or on-line), in an on-line publicly accessible registry dedicated to the dissemination of clinical trial information such as

ClinicalTrials.gov, or in journals willing to publish in abbreviated format (e.g., for studies with negative

or incomplete results).

l. The study protocol must explicitly discuss beneficiary subpopulations affected by the item or service

under investigation, particularly traditionally underrepresented groups in clinical studies, how the

inclusion and exclusion criteria effect enrollment of these populations, and a plan for the retention and

reporting of said populations in the trial. If the inclusion and exclusion criteria are expected to have a

negative effect on the recruitment or retention of underrepresented populations, the protocol must discuss

why these criteria are necessary.

m. The study protocol explicitly discusses how the results are or are not expected to be generalizable to

affected beneficiary subpopulations. Separate discussions in the protocol may be necessary for

populations eligible for Medicare due to age, disability or Medicaid eligibility.

The principal investigator must submit the complete trial protocol, cite where the detailed analysis plan for

the CMS CED questions occurs in the protocol, and provide a statement addressing how the study satisfies

each of the standards of scientific integrity (a. through m. listed above), as well as the investigator’s contact

information, to the email address below. The information will be reviewed, and approved trials will be

identified on the CMS Website.

The Email address for protocol submissions is: clinicalstudynotification@cms.hhs.gov. The Email subject

line should be: "CED Monoclonal Antibodies for the Treatment of Alzheimer’s Disease [name of

sponsor/primary investigator]"

Monoclonal antibodies directed against amyloid indicated for the treatment of AD are

covered when furnished according to the FDA approved indication in National Institutes of

Health (NIH)-supported trials.

For any CMS-approved study, or NIH-supported trial, that includes a beta amyloid positron emission

tomography (PET) scan as part of the protocol, it has been determined that these trials or studies also meet

the CED requirements included in the Beta Amyloid PET in Dementia and Neurodegenerative Disease NCD

(220.6.20).

C. Nationally Non-Covered Indications

Monoclonal antibodies directed against amyloid for the treatment of AD provided outside of an FDA-approved randomized controlled trial, CMS-approved studies, or studies supported by the NIH, are

nationally non-covered.

D. Other

N/A.

(This NCD last reviewed April 2022.)