Re: Medicare Coverage/Reimbursement of Facial Lipoatrophy Options...

[Guest guest]

Thank you for posting this. I had a Sculptra treatment done on March 26 and have asked my dermatologist to bill Medicare. His billing manager tells me that he can't find the codes to bill Medicare. He further stated that Medicare would only cover cost of Sculptra but NOT the doctor's fees of injecting it. I hope it isn't true as I get my Sculptra under the PAP and only pay the injecting fee which incidentally is now $600 a kit. It used to be $500. I can't find a competent provider for less than that in Atlanta.

I will appreciate it if anybody can tell me the codes for this procedure to bill Medicare.

VJ

In a message dated 4/12/2010 1:37:57 P.M. Eastern Daylight Time, nelsonvergel@... writes:

This the reply from the Jo Baldwin from CMS. As you can tell, there is still a lot of work they need to do in establishing rates, etc. I will keep following up for updates.

nelson

(Background for this email for those who have not read Medicare's decision: http://www.hivandhepatitis.com/recent/2010/0326_2010_a.html )

Dear Mr. Vergel,

I hope to be able to help with some of your questions. Please see the below responses and please let me know if you have additional questions.

1- Do patients have to remain depressed to get yearly touch ups ?

I do not know exactly how local Medicare contractors will implement the policy so there is always potential for variation in implementation when the national coverage policy is not explicit. I would venture to say that some documentation would continue to exist in the patient’s medical record that depression is a continued concern and that these conversations be had between the patient and their treating physician. But again, the policy is not explicit in this regard.

2- Are Sculptra and Radiesse (the two FDA approved options) to be included in Medicare part D formularies?

I do not believe these products fall under Part D Medicare coverage. For example, if the injections are delivered in a physician’s office, then the physician would purchase the fillers and then bill Medicare for the fillers and for administering the injections. Part B co-pays and deductibles would apply to this service just as it would be applied to any other Medicare covered service.

3- How much will doctors get paid for every session?

The payment amounts are in the process of being established. Medicare participating providers would accept the payment amount as the full payment but again, co-pays for each office visit would still apply just as any other Medicare Part B service.

4- Will there be a maximum number of sessions per year allowed?

The national coverage policy does not limit the number of sessions per year.

Sent: Wednesday, March 31, 2010 10:53 AMBaldwin, Jo F. (CMS/OCSQ)Subject: From the feedback tool - 100331-000018

Regarding:Decision Memo for Dermal injections for the treatment of facial lipodystrophy syndrome (FLS) (CAG-00412N)

I have the following questions:

1- Do patients have to remain depressed to get yearly touch ups ?

2- Are Sculptra and Radiesse (the two FDA approved options) to be included in Medicare part D formularies?

3- How much will doctors get paid for every session?

4- Will there be a maximum number of sessions per year allowed?

Thank you

Vergel

Founder

FacialWasting.org